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Regional  Topographical 
Dermatology 


ELEMENTARY  MANUAL 


Regional    Topographical 
Dermatology 


R.   SABOURAUD 

Director  of  the  City  of  Paris  Dermatological  Laboratory 
St.  Louis  Hospital 


ENGLISH  TRANSLATION 


C.  F.  MARSHALL 

Late  Assistant  Surgeon  to  the  Hospital  for  Diseases  of  the 
Skin,   Blackfriars,   London 


JVith  231  Illustrations  in  the  Text 


NEW  YORK  LONDON 

MAN  COMPANY  j^^g  REBMAN  LIMITED 

1123  BROADWAY  129  SHAFTESBURY  AVENUE 


PUHLISUKU  JUNK  4'1'H,  1905,  IN  FRANCE. 

PRIVILEGE  OF  COPYRIGHT  IN  THE  UNITED  STATES 

RESERVED  UNDER  THE  ACT  APPROVED 

MARCH  3D,  1905,  KY  MASSON  ET  GIF. 

ALL  RIGHTS  TO  COPYRIGHT  AND  ALL  COPYRIGHTS 

OF  THE  ORIGINAL  FRENCH  AND  TRANSLATION 

INTO    THE    ENGLISH    LANGUAGE,  IN    THE 

UNITED     STATES    OF     AMERICA     ARE 

ASSIGNED  BY   MASSON  ET  CIE   TO 

REBMAN  COMPANY,  NEAV  YORK 

COPYRIGHT,  1906, 

BY  REBMAN  COMPANY,  NEW  YORK. 

ALL  RIGHTS  RESERVED. 

THIS    ENGLISH    TRANSLATION    IS    PRINTED    FROM 

PLATES  MADE  WITHIN  THE  UNITED  STATES 

OF  AMERICA,  FROM   TYPE  SET  WITHIN 

THE  UNITED  STATES  OF  AMERICA 


ENTERED  AT  STATIONERS  HALL,  1906 
BY  REBMAN  LIMITED,  LONDON 


(^6(, 


PREFACE 


If  a  student  meets  with  a  cutaneous  disease  which  he  does  not 
know  to  be  Scabies,  we  cannot  suppose  that  he  would  consult  in  the 
special  treatises  the  article  Scabies,  more  than  any  other. 

On  the  contrary,  the  student  confronted  with  this  disease  will 
easily  notice  its  regional  localisations,  and,  observing  its  predom- 
inance on  the  hands  and  wrists,  will  consult  in  this  volume  the 
article  on  the  IVrist,  which  has  six  pages,  or  the  article  on  the 
Hands,  which  has  twenty  pages,  and  will  recognise  without  diffi- 
culty the  paragraph  concerning  the  disease  which  he  observes.  He 
will  find  there  its  name  and  essential  characters,  what  is  known  of 
its  nature  and  a  resume  of  its  treatment.  If  he  desires  fuller  infor- 
mation he  will  refer  to  the  classical  treatises,  in  order  to  study 
scabies  in  all  the  forms  in  which  it  may  occur. 

Thus,  a  work  of  this  kind  does  not  only  include  articles  on 
Eczema,  on  Psoriasis  or  on  Impetigo,  etc.,  but  it  also  contains  arti- 
cles on  the  Face,  the  Hand,  the  Leg,  etc.,  where  the  reader  will 
find  studied  the  principal  dermatological  types  of  each  of  these 
regions. 

This  book  is  thus  a  manual  of  Topographical  and  Regional 
Dermatology.  It  realises  in  the  study  of  cutaneous  diseases  what 
io  represented  in  elementary  botany  by  the  Dichotomons  Flora,  w'hich 
furnish  the  means  of  recognising  a  plant  when  it  is  met  with  for  the 
first  time. 

In  fact,  this  book  is  a  practical  manual  of  dermatology,  and  has 
no  pretension  to  be  more.  It  is  a  book  for  the  hospital  student  and 
the  practitioner  in  his  consulting  room. 

Compared  with  the  large  volumes,  which  study  a  single  question 
under  all  its  aspects,  this  book  condenses  into  660  pages  all  which 


vi  PREFACE. 

the  student,  and  especially  the  practitioner,  should  know  of  der- 
matology in  order  to  be  efficient  for  their  daily  work. 

Lastly,  in  practice,  Svpiiilogkai'IIv  is  inseparable  from  derma- 
tology, and  lesions  of  the  face  and  body  cannot  be  passed  by  in 
silence  under  the  pretext  that  they  belong  to  the  artificially  limited 
domain  of  syphilography.  A  description  of  these  lesions  will  there- 
fore be  given,  as  condensed  as  possible,  so  that  this  manual,  on  this 
subject  as  on  all  others,  may  preserve  its  elementary  character. 

In  one  respect  at  least  this  work  is  the  first  of  its  kind,  for  all 
the  books  on  dermatology,  hitherto,  presume  the  reader  to  have 
at  least  a  partial  knowledge  of  what  they  treat.  This  book,  on  the 
contrary,  starts  with  the  first  principle  of  all  teaching:  that  he  ivho 
learns  should  be  supposed  not  to  kiiozc. 

The  multiplicity  of  the  subjects  treated  prevents  an  encyclo- 
paedic book  from  being  exclusively  personal.  In  writing  this  I 
have  several  times  derived  assistance  from  the  works  of  others  and 
I  have  quoted  their  authors  as  much  as  possible.  With  regard  to 
the  figures  taken  from  other  sources  I  have  always  scrupulously 
indicated  their  origin.  Mr.  Rubens  Duval,  house  surgeon,  has  given 
me  much  assistance  in  the  dry  work  of  correction,  which  is  rendered 
difficult  by  the  fragmentary  nature  of  the  text,  and  I  here  tender 
him  my  thanks. 

Paris         •  SaboURAUD 


TRANSLATOR'S  PREFACE 


The  name  of  Sabouraiid  is  now  well  known  wherever  dermatology 
is  studied,  and  anv  book  from  his  pen  is  welcome.  The  present 
volume  is  not  only  remarkable  for  the  originality  of  the  regional 
method  adopted,  but  also  for  its  completeness,  and  for  the  inclusion 
of  certain  subjects  which  are  too  often  omitted  from  works  on  der- 
matology. 

Certain  dermatologists  have  a  tendency  to  become  too  exclusive 
and  to  lose  all  sense  of  proportion  in  their  study  of  the  skin.  This 
should  be  regarded,  not  as  a  thing  apart,  but  as  one  element  in  a 
complex  mechanism. 

Sabouraud  takes  a  wide  and  scientific  view  of  dermatology,  and 
included  in  thi']  book  will  be  found  a  description  of  the  exan- 
thematous  fevers,  a  good  account  of  syphilis,  including  the  extra- 
genital chancres,  and  some  of  the  complications  of  gonorrhoea.  It 
is  true  that  secondary  syphilides  receive  some  attention  in  other 
text  books,  but  chancres  are  ignored,  and  as  for  gonorrhoea,  it  is  con- 
sidered bad  form  by  some  to  recognise  its  existence.  This  is  a  form 
of  hyper-specialisation  which  is  totally  foreign  to  the  true  scientific 
spirit.  A  careful  study  of  Sabouraud's  book  will  show  the  importance 
of  taking  a  wider  view  of  the  subject;  a  course  which  will  tend 
both  to  the  benefit  of  the  patient  and  the  reputation  of  the  physician. 

In  conclusion  I  must  thank  l^r.  Sabouraud  for  his  courteous 
replies  to  questions,  and  Mr.  George  Fernet  for  some  useful  help. 
For  the  sake  of  convenience  I  have  given  the  approximate  English 
equivalents  of  the  prescriptions,  in  proportions  to  the  ounce. 

C.  F.  M. 


Regional  Dermatolo 


gy 


THE    FACE. 


The  face,  considered  as  a  whole,  is  a  single  region  for  the 
dermatologist,  but,  in  detail,  it  is  formed  by  several  distinct 
regions ;  the  forehead,  nose,  cheeks,  eyebrows,  moustache,  beard, 
lips  and  eyelids ;  each  of  which  may  form  a  small  chapter  in 
cutaneous  pathology. 

Before  considering  each  of  these  chapters  separately  I  shall 
speak  of  the  dermatology  of  the  face  in  general,  and  deal  suc- 
cessively with  the  dermatoses  which  it  presents  in  infancy, 
adolescence,  adult  age  and  old  age. 


Eczema 
lings 


of     Suck- 


p.    2 


Naevi  . P-    4 

Ephelides p.    5 


From  the  beginning  of  existence  a  pruriginous 
and  weeping  eczema  of  the  face  may  occur  which 
appears  connected  ivith  digestive  disorders  in  the 
newly  born:  Eczema  of  sucklings,  eczema  of  den- 
tition, teething  eruptions,  etc 

It  is  also  in  the  first  infancy  that  birth  marks  may 
raise  the  question  of  therapeutic  intervention   .    .    . 

The  same  with  Ephelides  and  lentigines  .... 

On  these  regions,  some  years  later.  Xeroderma]  ^ 

pigmentosum  may  arise;  a  rare  and  consanguineous  IXeToderma  ....  p.    6 
disease J 

The  face  is  a  common  situation  for  impetigo  "'"Li,-iinetigo  ...  p.    7 

children J 

One   may   also    observe   "tetters"   in   all  regions^  Tetters P-  lO 

(Pityriasis  Alba  faciei)  of  the  older  authors    •    •    -j" 

Also  epidemic  trichophytosis;  marked  by  circles  or^  ^  .  ,      ,    ^     .  ^  ,, 

/    ,    .    ,  ,       j:     T  •     1  I  Trichophytosis    .    .  p.  n 

segments  of  circles,  more  or  less  nncly  vesicular  .    .j 

One  sees  also  in  adolescents,  an  impetiginous 
form  of  eczema  in  placards  on  the  face,  accompa- 
nied by  diminished  acidity  of  the  urine  and  albu- 
minuria   

Towards  the  time  of  puberty  occurs  seborrhoea}       ,       ,  „  _. 

,  ,,                 ^       T      J       J  i  f  Seborrhoea    .    .    .    .   p.  I3 

of  the  nose,  forehead  and  face j 

.    .    .  and    the    different    forms    of    acne    which\ 
,.        ,         .       ,          .  ^Acne  Polymorphe  .   p.  15 

directly  arise  from  it J 


Impetiginous      E  c- 
zema p.  12 


THE    FACE. 


One  observes  also  chronic  congestive  conditions^ 
of  the  face  in  adolescents,  affecting  the  ears,  hands  L 
and  nose — erythema  pernio  and  chilblains  ....  J 

According  to  many  authors,  these  lesions  are- 
related  to  lupus  erythematosus.  This  has  only  an 
elective  localisation  for  the  face,  for  it  is  often 
seen  elsewhere;  but  this  localisation  exists  too  fre- 
quently   to    he    ignored 

The  infiltrated,  hypertrophic  and  ulcerated  lesions'] 
of  tuberculous  lupus,  also  very  common  on  the  I 
face,  are  important J 

.  .  .  and  the  papular  eruptions  of  Secondary^ 
Syphilis J 

Tubercular  leprosy  of  the  face,  although  rarely  1 
observed   in    our   country,    cannot   be   passed   over 
in  this  enumeration      

Erysipelas  of  the  face,  although  belonging  more] 
to  general  pathology,  requires  a  brief  notice   .    .    .1 

Also  Darier's  disease,  in  spite  of  its  extremes 
rarity J 

/  shall  next  speak  of  Chloasma,  or  "Uterinc) 
Mask" J 

.  .  .  and  of  Vitiligo,  the  discoloured  patches  of} 
which  have  the  face  for  one  of  their  seats  of  I 
election I 

The  face,  like  the  extremities,  is  exposed  to  trau-] 
viatic  eruptions,  especially  to  dermatitis  caused  by  L 
dyes 

Mature  age  and  senility  have  also  their  der- 
matological  pathology,  special  to  the  face;  for 
example  acne  rosacea  and  acne  of  the  age  of 
decline 

Later  in  life  occurs  the  flat  brown  wart  called'] 
senile  or  concrete  seborrhoea  .  .  .  and  finally  I 
Epithelioma 

/  shall  conclude  by  describing  Mycosis  fungoidcs] 
of  the  face;  and  cutaneous  lymphadenia,  or  per-  I 
nicious   lymphodermia      


Erythema  pernio. 
Chilblain  .    .    . 


p.  17 


Lupus  Erythemato- 
sus     p.  18 


Tuberculous  lupus,  p.  20 


Secondary    Syphilis  p.  22 


Leontiasic    leprosy,  p.  23 


Erysipelas  of  the 
face 

Follicular  P  s  o  r  o- 
spermosis  .... 


p.  24 


Chloasma 


P-25 
p.  26 


Vitiligo 


p.  27 


Artificial  dermatitis  p.  28 


-  Acne  rosacea  •    .    .  p.  29 

Senile  wart.     Con- 
crete Seborrhoea.   p.  30 
Epithelioma  .    .    .  p.  31 
Mycosis  fungoides.   p.  33 
Cutaneous    Lymph- 
adenitis   .    .    .    •  p.  34 


ECZEMA   OF   SUCKLINGS. 


Eczema  of  sucklings  usually  commences  about  the  4th  or  5th 
month,  whatever  the  mode  of  feeding:  maternal,  mixed  or  bottle. 
It  may  or  may  not  coincide  with  appreciable  digestive  troubles. 


THE    FACE.  3 

It  begins  on  the  cheeks,  forehead,  and  chin  in  the  form  of  a  crop  of 
red  points,  which  are  histologically  vesicles,  excoriated  by  scratch- 
ing. Their  number  increases  so  as  to  form  adjoining  placards. 
The  natural  orifices :  the  eyelids,  nostrils  and  mouth,  and  their 
immediate  neighbourhood  are  nearly  always  exempt. 


Fig.    1.     Eczema   of   Suckling.      (Brocq's   patient.      (Photo   by    Sottas.) 


These  lesions,  very  congestive,  present  a  more  or  less  marked 
exudation.  In  some  cases  the  exudation  is  reduced  to  a  mini- 
mum ;  then  the  lesion  is  red,  glazed  and  covered  with  darker 
points  than  the  excoriated  vesicles.  When  the  exudation  is  abun- 
dant, it  forms  amber  coloured  opalescent  crusts,  sometimes  tinged 
with  blood,  rarely  thick,  adherent  and  often  crackled  (Fig.  i). 
Every  day  brings  forth  one  or  more  congestive  crises,  with  itch- 


4  THE    FACE. 

ing,  scratching  and  weeping.  The  lesions  increase  from  the  4th 
to  the  6th  month  and  then  diminish,  disappearing  towards  the 
loth  or  nth  month.  There  are  intense  forms  which  attack  the 
body,  and  benign  forms  Hmited  to  the  cheeks  and  hardly  recog- 
nizable, the  lesions  of  which  disappear  almost  as  soon  as  they  are 

formed. 

The  etiology  of  this  eczema,  like  all  others,  remains  obscure. 
However,  this  form  appears  to  be  connected  sometimes  with  over- 
feeding or  irregular  feeding;  at  other  times  with  intolerance  of 
the  digestive  tube  for  an  exclusive  milk  diet.  In  these  cases, 
after  the  first  tooth  is  cut,  the  best  flour  must  be  given  and  the 
feeding  bottles  boiled.  It  appears  that  the  stomach,  which  cannot 
digest  the  fat  of  milk  or  casein,  digests  better  all  the  other  hydro- 
carbons, starches  and  sugar.  For  example :  milk  and  flour,  bar- 
ley, rice  and  wheat  water,  diluted  according  to  age.  In  the  most 
severe  cases  starchy  foods  may  be  given  before  the  eruption  of 
the  first  teeth.  This,  when  done  carefully,  is  often  most  success- 
ful, but  requires  careful  supervision. 

At  this  age  no  dressing  is  tolerated,  and  no  topical  applications 
are  of  any  value  except  protective  pastes,  such  as  equal  parts  of 
oxide  of  zinc  and  fresh  vaseline  or  lard.  Cleanse  daily,  without 
soap,  with  sweet  oil  of  almonds. 

Moist  dressings  covered  with  protective  may  be  tried,  espe- 
cially on  the  scalp.  This  aids  removal  of  the  crusts,  which  may 
also  be  done  by  the  application  of  vaseline  for  24  hours :  when 
this  does  not  provoke  weeping.  At  the  period  of  retrogression, 
the  addition  of  oil  of  cade  to  zinc  paste  hastens  the  disappearance 
of  the  lesions.  The  proper  treatment  of  this  form  of  eczema  is 
dietetic :  all  external  treatment  is  symptomatic. 

NAEVI    OF   THE   FACE. 

These  are  very  common  at  birth  and  tend  to  progressive  retro- 
gression which  causes  most  of  them  to  disappear.  The  physician 
should  bear  this  in  mind. 

The  dimension  of  those  which  persist  varies  from  a  fine  point 
to  the  size  of  the  hand ;  the  former  are  trivial,  the  latter  impvortant. 
They  may  thus  be  divided  into  two  classes ;  those  which  increase 
in  size  and  those  which  do  not.  Treatment  may  be  reserved  for 
the  latter,  but  is  indicated  in  those  which  increase  in  size. 


THE    FACE.  5 

They  may  be  flat,  projecting  or  framboesiform ;  flat  nsevi  form 
a  diffuse  placard,  or  one  surrounded  by  vascular  rays.  The  fram- 
boesiform naevi  should  be  destroyed  with  the  galvano-cautery, 
and  the  vascular  rays  which  surround  them  punctured  with  the 
fine  point  of  the  cautery;  this  proceeding,  when  carefully  per- 
formed, leaves  no  scar. 

Naevi  in  placards  should  be  treated  by  electrolysis.  For  the 
smallest,  unipolar  electrolysis  is  used,  the  positive  needle  being 
inserted  in  the  centre  of  the  nsevus  and  the  negative  electrode 
held  in  the  patient's  hand  (20-25  milliamperes)  till  the  white 
zone  produced  by  the  current  around  the  needle  reaches  3  to  5 
millimetres  in  width. 

For  large  naevi,  bi-polar  electrolysis  is  required.  The  positive 
needle  remaining  in  the  centre  of  the  nsevus,  the  position  of  the 
negative  needle  is  changed  around  it,  leaving  it  in  long  enough 
to  produce  a  white  zone  of  4  millimetres  each  time.  The  needle 
should  only  be  inserted  and  withdrawn  after  interruption  of  the 
current,  to  avoid  pain.  The  maximum  is  15  to  20  milliamperes, 
beyond  which  there  is  risk  of  necrosis  and  cicatrices. 

Vaccination  on  naevi  may  be  employed  for  those  of  the  body, 
The  resulting  cicatrix  does  not  render  this  method  suitable  for 
the  face. 

The  treatment  of  naevi  which  do  not  increase  in  size  should  be 
practised  when  the  dimensions  require  it,  and  when  the  child  is 
sufficiently  intelligent  to  submit  to  it  without  struggling. 

EPHELIDES. 

Under  the  term  Ephelides  are  included  coloured  spots  more  or 
less  abundant,  appearing  during  the  course  of  second  infancy, 
more  marked  or  more  numerous  in  summer  than  in  winter  and 
more  common  in  blondes  than  in  brunettes.  These  hyperchromic 
symmetrical  spots  are  situated  especially  on  the  exposed  parts, 
the  face  and  hands.  Local  treatment  is  deceptive,  for  the  spots 
are  apt  to  recur.  Treatment  consists  in  the  application  of 
exfoliatives. 

Apply  at  night  equal  parts  of  oxide  of  zinc,  vaseline  and  resor- 
cin  {Unna),  for  3  or  4  days,  after  which  the  face  is  covered  with 
a  varnish  or  paste.  When  the  epidermis  is  detached  the  whole  is 
removed  like  a  mask. 


6  THE   FACE. 

Darier  prefers  the  following,  applied  with  a  brush  for  three  nights: 

Tincture  of  potash  soap 40  grammes    $i 

Resorcin aa.  10  "  3ij 

Precipitated  sulphur 

This  is  left  to  dry  and  covered  in  the  morning  with  powder  or 
cream.  Desquamation  occurs  on  the  eighth  day.  All  these  pro- 
ceedings are  painful. 

LENTIGO. 
The  spots  of  lentigo  ("beauty-spots")  are  nsevi,  varying  in  num- 
ber, but  generally  few  in  each  subject.  They  are  disseminated  irreg- 
ularly, and  characterised  by  regular  dark  coloured  spots,  some  fiat, 
others  irregularly  warty,  hairy,  etc.  We  are  only  concerned  with 
lentigines  of  the  face,  where  by  their  size  or  number  they  may  be 
disfiguring.    The  treatment  is  the  same  as  for  neevi. 

XERODERMA    PIGMENTOSUM. 
I  shall  only  say  a  few  words  concerning  this  congenital,  hered- 
itary affection,  described  and  named  by  Kaposi.     It  is  situated  on 

the  face,  neck,  hands  and 
wrists.  In  these  regions 
'"    """"■■'"  '"•■  "^*  the  skin  is  covered  with 

pigmented  spots  of  differ- 
ent tints,  and  varying  in 
''■v  size    from    3    to    6    or    7 

millimetres.     These  spots 
appear     in     infancy,     and 
ny^  become    more    and    more 

pronounced ;  they  are  red 
at  first,  then  brown  and 
^  l^^^^M-'  black.      The     spots     ulti- 

mately undergo  an  atro- 
phic and  cicatricial  evolu- 
tion. The  mixture  of  the 
cicatrices  with  the 
younger  spots  gives  a 
characteristic  marbled 
aspect  to  the  face.  This 
Cl'a^'^'f.  disease,  which  appears  to 

be    benign,    causes    pro- 

Flgr.  2.     Xeroderma  pigmentosum.      (Quinquaud's         ,  ,      ,  •         «  .  . 

patient.     St.  Louis  Hosp.  Museum,  No.  1464.)  lOUnd  ChaUgeS  m  the  sklH, 


THE    FACE.  7 

which  becomes  thin  and  contracted.  Later  on  this  condition  may 
become  compHcated  by  multiple  mahgnant  tumours,  sarcomas  and 
epithehomas,  which  multiply  and  increase  to  the  point  of  causing 
death  of  the  patient  in  15  or  20  years.  Sometimes  these  epitheliomas 
remain  benign  and  the  patient  may  survive,  but  this  is  rare.  The 
family  character  of  the  disease  is  evident;  its  cause  unknown;  its 
treatment  nil. 

The  face  and  hands  should  be  protected  against  the  action  of 
the  sun,  which  is  harmful.  Pastes  of  oxide  of  zinc  are  sufficient; 
to  which  chlorate  of  potash  (i  in  30)  may  be  added  when  there  is 
a  tendency  to  epithelioma. 

IMPETIGO. 

Impetigo  is  especially  an  affection  of  children,  and  of  the  face, 
although  it  may  be  observed  at  all  ages  and  on  all  parts  of  the 
body. 

The  primary  lesion  is  a  thin  clear  phlyctenule,  which  soon  rup- 
tures and  exudes  serum  in  large  drops.  This  serum  dries  in 
amber  coloured  scabs,  covering  the  epidermic  exulceration  like 
sealing  wax.  Around  the  first  scab  a  new  phlyctenular  ring 
forms.  This  in  its  turn  ruptures,  empties  itself,  and  fades  away. 
The  turbid  serum  exuded  is  added  to  the  scab,  which  becomes 
hard.  Under  the  scab  the  lesion  is  covered  with  a  thin  fibrinous 
film,  of  a  pale  lilac  colour,  which  is  characteristic.  It  increases 
for  some  days  under  the  scab,  then  dries  up  and  heals,  generally 
in  15  days,  without  leaving  scars. 

This  lesion  is  never  single,  the  impetigo  proceeding  by  crops, 
(ab  impetu).  The  face  presents  from  5  to  50  successive  lesions 
in  all  stages  of  evolution.  There  is  an  impetigo  of  the  conjunc- 
tiva (phlyctenular  keratitis  p.  133)  which  is  accompanied  by  in- 
tense photophobia,  and  if  neglected  ends  in  definite  corneal 
opacity  (leucoma).  There  is  also  an  impetigo  of  the  nostrils 
(anterior  impetiginous  rhinitis)  which  is  very  persistent  and 
even  chronic,  and  the  cause  of  many  recurrent  impetigos  of  the 
face.  There  is  a  commissural  impetigo  of  the  lips,  (perleche) 
and  a  chronic  impetigo  of  the  retro-auricular  furrow.  Impetigo 
of  the  face  may  be  inoculated  on  the  exposed  parts:  the  neck, 
wrists  and  hands:  on  the  fingers  it  forms  phlyctenular  periony- 


g  THE    FACE. 

chosis;  it  is  often  inoculated  on  the  legs,  the  ankles  and  feet, 
where  the  lesion  may  become  ulcerative,  (ecthyma). 

The  primitive  lesion  of  impetigo  contains  a  serous,  non-puru- 
lent liquid,  which  becomes  purulent  quickly  by  secondary  infec- 
tion ;  but  even  then  the  liquid  is  clearer  than  true  pus. 

The  impetiginous  lesion  is  streptococcic.  The  liquid  which  it 
contains,   transferred   to   boullion    serum,   gives    in    12   hours    at 


Fig.    3.      Impetigo    Contagiosa    of    the    face    (Streptococcic). 
(Quinquaud's    patient.       St.    Louis    Hosp.    Museum,     No.     1424.) 

37°C.  an  almost  pure  culture  of  Streptococcus,  which  can  be  puri- 
fied by  dilution  and  by  passage  through  successive  tubes  of  gelose 
urine,  on  which  definite  separation  is  obtained.  The  culture  of 
Streptococcus  is  obtained  from  all  impetiginous  lesions.  We  shall 
refer  to  this  frequently. 


THE    FACE.  g 

The  secondary  suppuration  of  impetiginous  lesions  results  from 
their  infection  by  white  and  yellow  Staphylococci,  which  grow 
in  a  very  few  hours.  Direct  culture  on  gelose  peptone  renders 
them  evident.  They  are  always  distinct  from  the  colonies  of 
Streptococci. 


Fig.   4. 


Impetigo   Contagiosa   of   ih,     l;n  <     (Streptococcic).      (E.    Besnier's   patient. 
St.    Louis    ilosp.    Museum,    No.    487.) 


These  Staphylococci  may  cause,  among  the  Streptococcic 
lesions  described  above,  lesions  of  the  follicular  orifices,  pustular 
from  the  first,  which  result  from  Staphylococcic  reinoculations, 
and  may  be  objectively  distinguished  from  the  preceding. 

The  treatment  of  acute  impetigo  is  entirely  external.  When 
well  carried  out  it  gives  excellent  results. 


10  THE    FACE. 

(i)  Remove  all  the  scabs  carefully,  either  by  immediate 
scraping,  or  after  having  softened  them  for  several  hours  with 
fomentations. 

(2)  Immediately  afterwards — 20  times  a  day — apply  the  follow- 
ing lotion  on  absorbent  wool  with  light  but  repeated  friction : — 

Distilled  water  (camphorated  to  sat-j^QQ  grammes  Oi 

uration    and    filtered)      J 

Sulphate    of    zinc      2  "  3i 

Sulphate  of  copper I  gramme    3ss. 

Let  this  dry  without  wiping  and  repeat.  Never  use  moist  dress- 
ings with  this  liquid  under  impermeable  coverings.  At  night 
apply  a  zinc  paste  of  equal  parts  of  oxide  of  zinc  and  lard,  or 
vaseline. 

Avoid  removing  the  scabs  by  force  when  they  are  thin  and  do 
not  project  above  the  level  of  the  skin.  Do  not  be  afraid  of  the 
green  colour  which  the  sulphate  of  copper  gives  to  the  scabs. 

When  a  lesion  increases  in  spite  of  treatment,  carefully  raise 
the  borders  of  the  growing  phlyctenule  and  carry  the  antiseptic 
liquid  under  the  borders  by  a  little  friction. 

A  solution  of  nitrate  of  silver  (7  per  cent.)  may  be  used  instead 
of  the  above  solution,  but  has  the  disadvantage  of  staining. 

Vide  Eye,  for  the  treatment  of  phlyctenular  keratitis  (p.  133). 

Vide  Nostrils,  for  the  treatment  of  chronic  nasal  impetigo 
(p.  84). 

Vide  Lips,  for  the  treatment  of  commisural  impetigo  (p.  75). 

Vide  Ears,  for  the  treatment  of  retro-auricular  impetigo 
(p.  no). 

Vide  Legs,  for  the  treatment  of  ulcerative  impetigo,  (ecthyma) 
(p.  296). 

Vide  Fingers,  for  the  treatment  of  impetigo  of  these  regions 
(p.  368). 

Vide  Nails,  for  the  treatment  of  impetiginous  perionychosis 
(P-  376). 

"TETTERS."* 
(Pityriasis  alba  faciei  of  the  old  authors.) 

This  is  seen  among  the  lesions  of  impetigo  (see  the  preceding 
article),  or  in  connection  with  chronic  lesions  left  by  a  former 

♦Translator's  Note.  The  name  in  the  original  is  "Dartre  volante." 
T)t  Sabouraud  has  suggested  "Tetters"  as  the  nearest  equivalent  in  Eng- 
lish.    Both  are  old-fashioned  terms,  but  are  explained  in  the  text 


THE    FACE. 


II 


acute  impetigo,  perleche,  impetigo  of  the  nostrils,  and  retro- 
auricular  impetigo,  or  even  in  the  absence  of  all  recognisable  impeti- 
ginous lesions.  It  is  a  dry  streptococcic  dermatitis,  and  so  to  speak 
an  abortive  pityriasiform  impetigo. 

Each  lesion  is  minute,  finely  scurfy,  ill  defined  and  usually 
localised  on  the  side  of  the  chin,  the  cheeks,  forehead  or  neck. 
All  intermediate  forms  exist  between  crustaceous  impetigo  and 
this  dry  slightly  scaly  rash. 

Applications  of  the  following  preparations  daily,  or  twice  daily, 
cause  the  lesion  to  quickly  disappear ;  but  it  often  reappears  else- 
where. The  primary  lesion  must  be  sought  for  and  treated  in 
the  eyelids,  nostrils  and  behind  the  ear. 


aa.  30  centigrammes 


Vaseline 

Calomel      

Ethereal  solution  of  tannin   .      30  grammes 


.gr.  V. 


TRICHOPHYTOSIS. 


■"/ 


We  shall  deal  with  trichophyton  of  the  beard  and  neck  in  the 
adult  in  their  proper  places  (p.  156  and  170).     I  shall  only  refer 

here  to  Trichophyton  of 
the  smooth  skin  of  the 
face.  It  is  common,  mul- 
tiple, and  generally  mi- 
nute. It  always  accom- 
panies ringworm  of  the 
scalp  in  the  child  by  acces- 
sory and  transient  inocu- 
lation of  the  smooth  skin. 
It  consists  of  rose-col- 
oured spots,  slightly  pap- 
ular, irregular  and  squam- 
ous, which  tend  to  spon- 
taneous disappearance. 

If    the     spots     enlarge 
they    become   partly    sur- 

Fig.    5:      Ringworm    of    the    face.       (E.    Besnler's      fOUndcd        bv       E        QUartcr 
patient.      St.   Louis   Hospital   Museum,    No.    1710.)  .      1 1^         •       i 

or  half  circle,  which  is 
redder,  more  papular,  and  finely  and  irregularly  vesicular.  Some- 
times this  circle  is  complete   (Fig.  5).     The  presence  of  ring- 


,2  THE    FACE. 

worm  of  the  scalp,  and  microscopic  examination  or  culture  of  the 
squames,  confirms  the  diagnosis. 

Treatment  consists  in  daily  friction  with  tincture  of  iodine  in 
alcohol  (lo  per  cent.),  applied  on  wool  pledgets. 

IMPETIGINOUS   ECZEMA  OF  THE   FACE   IN  ADOLESCENTS. 

This  is  a  very  interesting  and  little  known  dermatosis.  It 
is  an  amicrobial  dermatosis;  finely  vesicular,  pruriginous,  and  exu- 
dative, with  impetiginous  scabs ;  a  moist  eczema,  situated  on 
the  face,  cheeks,  temples,  forehead  and  chin;  or  more  gener- 
alised on  the  neck,  in  the  flexures  of  the  elbow  and  hand,  in  the 
groin  and  genital  region,  etc.  Sometimes  it  is  chronic,  but  more 
often  it  occurs  in  sub-acute  crops,  with  intervals  during  which 
there  may  remain  a  red  and  slightly  moist  epidermatitis.  This 
disease  occurs  in  adolescents,  and  especially  in  young  girls  from 
ID  to  20  years  of  age. 

It  has  an  evident  relationship  to  the  prurigo  of  Hehra,  but  must 
not  be  confounded  with  this.  It  is  usually  very  localised.  The 
prurigo  of  Hebra,  even  when  it  affects  the  same  principal  regions, 
is  also  generalised  on  the  whole  body.  Prurigo  of  Hebra  is  only 
moist  secondarily ;  the  disease  in  question  always  so.  However, 
prurigo  of  Hebra  dates  from  infancy  and  disappears  with  age. 
The  disease  in  question  may  arise  at  12,  15  or  18  years,  without 
anterior  prurigo. 

It  is  accompanied  by  diminished  acidity  of  the  urine,*  often 
also  by  slight  albuminuria,  sometimes  intermittent. 

This  albuminuria  (o.io  to  o.  50  per  day)  is  sometimes  transient 
and  disappears  in  the  recumbent  position ;  or  it  may  coincide 
with  the  digestion  of  the  mid-day  meal.  There  may  also  be  an 
albuminuria  with   renal   lesions    (epithelial   casts),   consecutive   or 

*  The  urinary  acidity  may  be  tested  by  a  solution  of  carbonate  of  soda 
— made  so  that  a  cubic  centimetre  corresponds  to  a  gramme  of  acid 
(expressed  in  phosphoric  acid)  per  litre  of  urine,  using  20  cubic  centi- 
metres of  urine  for  examination.  The  neutralisation  obtained  is  verified 
by  the  equal  tints  of  red  and  blue  litmus  paper. 

To  find  the  normal  acidity  of  the  urine  of  any  subject,  the  biological 
coefficient  (weight)  of  the  subject  is  multiplied  by  0.03  (this  figure  repre- 
senting the  normal  acidity  by  the  urological  standard). 

Example.  In  a  subject  having  a  biological  coefficient  of  56,  the  normal 
acidity  would  be  56X0.03=1.69  for  24  hours,  ((acidity  expressed  in  phos- 
phoric acid).     (Note  by  DesmouHeres.) 


THE    FACE. 


13 


not  to  an  infection  (scarlet  fever  or  mumps).  In  this  case,  by 
treating  the  nephritis  by  milk  diet,  etc.,  the  eczema  is  cured. 

In  all  cases,  fresh  air,  vegetable  diet  with  eggs,  starchy  foods 
and  sugars  are  indicated :  the  attacks  becoming  less  frequent  and 
severe. 

Local  treatment  includes  applications  of  zinc  pastes,  nitrate  of 
silver  (5  to  10  per  cent.).  Some  cases  are  severe  and  last  for 
years,  but  are  always  curable. 

SEBORRHOEA. 

This  term  is  exclusively  limited  to  a  greasy  state  of  the  skin  pro- 
duced by  an  exaggerated  flow  of  sebum,  causing  the  latter  to  become 
visible. 

The  seborrhoeic  state  thus  defined  must  be  carefully  distin- 
guished from  others  improperly  called  by  the  same  name,  which 

are  characterised  by 
'f ^;^'-^''\>H' ..    ..;-"■  ;;{.  !;P^     dry     squames     (pity- 
riasis simplex),  or  by 
fatty   squames    (pity- 
^^^r„-^l     - ''v:--    ••:... ''T.^'^'.X'' .•,    ^>j     riasis      steatoides, 

squamous  eczema 
with  fatty  squames). 
A  squamous  condi- 
tion may  be  super- 
l  "  •••  ^^ -V''^'\''--N'""'T'<v^r"^'"^  ^''■,  '-^'."-''-vC  posed  on  a  sebor- 
•  .'.  '""'tV^nx  ""  ••  'VN' ^"^-•cJ'.'C^'J  rhoea  (pityriasis 
'.>A"tv;.  "  -t'^"*^  ,  •'  -v-"'-4S^T{'^-^j  "  -  ^/d  s  u  p  e  r  seborrlioica) , 
i^^i^^^^-^"^-^ .    '^  ,£:::l'^t^^^d,M§^^^S^-^'f'^  'J     'jwt  it  is  never  a  sebor- 

•^saiet=:     j-iioea.    Seborrhoea  is 

Fig.  6.  Microbacillus  of  Seborrhoea.  Extemporary  a  morbid  state  which 
pfeparation.     Obj.    immersion   1-12    Leitz.    Ocular   IV.  *t  iii<-»i  Uiu  bLdLC  willl,ll 

is  the  precursor  and 
sign  of  puberty.  The  elementary  lesion  is  formed  by  a  fatty  cylin- 
der situated  in  the  sebaceous  pores,  which  it  distends  and  ren- 
ders visible.  This  cylinder,  which  may  be  expressed  like  a  worm 
by  the  finger  nails,  when  spread  on  a  slide,  washed  with  ether 
and  stained  with  some  aniline  dye.  or  by  Gram's  method,  shows 
myriads  of  a  fine  bacillus,  the  seborrhoeic  microbacillus,  which  is 
the  constant  microbial  expression  of  seborrhoea  (Fig.  6.).     The 


14  THE    FACE. 

culture  of  this  microorganism,  although  not  very  easy,  can  be 
obtained  with  a  little  care  by  the  insertion  of  a  particle  from  the 
middle  of  a  seborrhoeic  cylinder  in  glycerin  peptone  gelose,  very 
slightly  acid,  (five  drops  of  glacial  acetic  acid  in  a  litre  of  the 
medium). 

Seborrhoea  thus  defined  appears  just  in  the  skin  of  the  nose  and 
nasal  fold,  the  chin  and  forehead.  In  many  cases  these  sebor- 
rhoeic regions,  at  first  distinct,  become  confluent,  and  the  whole 
face  becomes  seborrhoeic,  with  the  exception  of  the  natural 
orifices. 

True  seborrhoea  has  no  functional  symptoms  except  very  slight 
itching,  when  there  is  local  sweating. 

Seborrhcea  is  not  confined  to  the  face,  but  extends  over  nearly 
the  whole  of  the  axial  line  of  the  body,  with  predominance  in  the 
presternal  and  inter-scapular  regions.  It  is  observed  in  very  dif- 
ferent degrees  of  intensity.  Seborrhoea  is  accompanied  by  dif- 
fuse loss  of  hair  in  the  affected  region.  On  the  vertex,  where  it 
usually  occurs  at  the  age  of  19  or  20  in  man,  it  causes  masculine 
baldness.  On  the  face  and  on  the  body  seborrhoea  gives  rise  to 
acne  of  all  kinds,  which  we  shall  study  later. 

Seborrhoea  has  two  maximum  periods :  puberty  and  the  menopause, 
or  to  speak  generally,  the  age  of  evolution  and  the  age  of  involution. 
It  is  the  necessary  substratum  of  a  large  number  of  morbid  condi- 
tions; of  all  the  acnes;  a.  comedo;  a.  papulosa;  a.  indurata — s\!p- 
piirata — keloid — necrotica,  etc.,  and  the  frequent  substratum  of  a 
number  of  others:  pityriasis,  follicular  psorospermosis,  contagions 
flat  icart,  epithelioma,  etc. 

The  importance  of  this  morbid  state  is  considerable.  Sebor- 
rhoea with  all  the  eruptions  above  described  is  observed  most 
often  in  adolescence  and  in  young  girls.     It  increases  from  12  to 

15  years  and  usually  decreases  towards  20.  In  this  case  all  the 
sebaceous  pores  excrete  on  the  face  a  yellow  fatty  fluid,  which  in 
a  few  hours  accumulates. 

This  morbid  state,  extremely  distressing  when  it  attains  this 
degree,  requires  active  treatment.  Mild  preparations  should  be 
tried  first.  The  following  is  a  list  of  anti-seborrhoeic  applica- 
tions, arranged  in  order  of  strength. 

I.  Friction   twice   daily  with   Hoffmann's 

Liquor 200  grammes       5i 

Resorcin 2  "         gr.  5 


THE    FACE.  15 

2.  The  same  with  sulphur   soap   at  night. 

3.  The   same  in  the  morning  and  at  night  the 

application  with  a  brush  of: 

Precipitated   sulphur      ...    10  grammes     gr.  50 
Alcohol    (90  per  cent.)     100  "  51 

Aqua   dist 10  "  3i 

4.  Sulphur  Ointment  at  night 

Precipitated   sulphur  i  to  10  grammes  gr.  16-160. 
Vaseline 30  "  5i 

balicylic  acm      ^  ^^    ^^  centigrammes  to  4  grammes    gr.  8  to  64 
Resorcine-  J 

5.  Application  at  night  of  equal  parts  of  soft  soap  and  precipi- 

tated sulphur. 

This  is  followed  by  zinc  paste  at  night  if  the  irritation  is 
excessive. 

6.  Friction  with  pledgets  of  absorbent  wool   soaked  in  Carbon 

bi-sulphide  saturated  with  sulphur  (this  is  inflammable  at 
some  distance).  This  treatment  may  be  combined  with 
the  preceding. 

After  several  months  both  doctor  and  patient  perceive  that 
they  are  gaining  ground,  and  that  the  morbid  condition  is  dimin- 
ishing in  intensity. 

Benign  cases  require  only  the  mildest  of  the  preparations 
indicated.  No  internal  treatment  is  of  any  constant  value  in  the 
treatment  of  pure  seborrhoea,  and  the  same  may  be  said  of  rules 
of  diet. 

ACNE  POLYMORPHE. 

Acne  must  be  defined  by  its  immediate  cause.  The  history  of 
acne  is  that  of  microbial  infection,  secondary  to  the  microbacil- 
lary  fatty  cylinder  of  seborrhoea.  This  microbacillary  fatty  cylinder 
may  develop  largely  and  assume  a  utricular  form,  with  a  summit 
covered  with  pigmented  granulations,  appearing  as  black  points: 
Acne  comedo.  After  remaining  for  years  this  grows  excessively, 
and  degenerates ;  its  flora  disappear  and  it  is  reduced  to  an  epidermic 
shell  enclosing  fat. 

More  often  the  comedo  is  infected  with  white  staphylococci  at  the 
summit,  which  is  surrounded  by  a  red  spot.  The  comedo  then 
becomes  the  centre  of  a  generalised  inflammation,  more  or  less  acute, 
which  causes  either  an  abscess — acne  suppurata,  or  an  indurated 


i6 


THE    FACE. 


nodule  which  does  not  suppurate  and  is  slowly  absorbed— acn^ 
mdurata— or  undergoes  a  cystic  transformation.  The  foci  of  inflam- 
mation, when  they  are  contigu- 
ous, may  form  burrows  and 
irregular  fistulous  tracts  (espe- 
cially in  the  submaxillary  region 
and  the  neck). 

All  these  lesions  coexist  in  the 
same  face,  and  constitute  acne 
polymorphe  (Fig.  7).  This  has 
its  maximum  in  the  adolescent 
on  the  forehead,  nose,  cheeks, 
chin  and  sub-maxillary  regions. 
It  is  accompanied  by  similar 
lesions  of  the  trunk,  especially 
in  the  anterior  and  posterior 
thoracic  regions.  These  lesions 
may  occur  with  such  multiplicity 
as  to  cause  complete  disfigure- 
ment. 

A  similar  state  is  observed  in 
its  maximum  in  workers  in 
chlorine :  chloric  acne. 
The  treatment  of  polymorphous  acne  is  that  of  the  subjacent 
seborrhoea :  sulphur  ointments  and  lotions  applied  at  night  and 
washing  with  soap  in  the  morning.  The  doses  must  be  gradu- 
ated according  to  the  case  (pp.  14  and  15).  Sulphur  baths  assist 
external  medication. 

The  action  of  the  X-rays  on  polymorphous  acne  is  undeniable. 
They  should  be  applied  diffusely  in  sittings  every  15  or  18  days, 
with  3  or  4  units  H.  The  result  is  generally  evident  after  the 
third  sitting  and  more  permanent  than  after  most  external  appli- 
cations. 

In  acne  comedo,  expression  of  the  comedo  facilitates  the  action 
of  topical  applications  and  renders  them  more  efificacious.  In 
suppurative  and  indurated  acne,  opening  the  collections  of  pus 
with  the  fine  point  of  a  galvano-cautery  hastens  the  disappearance 
of  the  lesions.  Cauterisation  of  the  fistulous  tracks  of  pustular 
and  cystic  acne  with  a  crayon  of  nitrate  of  silver  may  be  required. 
A  course  of  strong  sulphur  water,  such  as  Challes,  St.  Boe's, 


FIgr.  7.     Acne       polymorphe.      (A.       Four- 

nier's    patient.     St.    Louis    Hospital 

Museum.    No.    1132.) 


THE    FACE.  17 

AUevard  or  Luchon,  tends  to  diminish  the  number  and  size  of  the 
lesions,  and  to  prevent  recurrence.  In  some  acnes  the  outbreaks 
appear  to  be  connected,  even  in  the  adolescent,  with  gastric  dis- 
orders. In  such  cases,  the  state  of  the  stomach  must  be  attended 
to.  More  often  acne  appears  related  to  sexual  development.  No 
uniform  rule  of  diet  can  be  prescribed,  based  on  the  acne  alone. 
Acnes  connected  with  uterine  disorders,  the  menopause  in 
women,  the  evolution  of  the  fifth  decade  in  men  will  be  studied 
later  (p.  30). 

PERMANENT  CONGESTIVE  STATES  OF  THE  FACE  IN 
ADOLESCENTS. 

Congestive  states  of  the  face  occur  in  adolescents,  some  of 
which  are  related  to  gastric  disorders,  others  to  bad  circulation 
depending  on  an  ill-defined  general  condition,  hitherto  called 
lymphatism  and  scrofula. 

FACIAL     CONGESTION     CONNECTED    WITH     GASTRIC     DIS- 
ORDERS. 

This  may  occur  both  in  the  adolescent  and  in  the  adult.  After 
each  meal,  especially  after  breakfast,  the  patient  experiences  con- 
gestion of  the  face.  At  the  same  time  the  extremities,  the  feet 
in  particular,  become  cold.  Gastric  digestion  may  be  arrested, 
and  is  hardly  complete  in  three  hours.  At  the  end  of  this  time 
the  facial  congestion  diminishes,  to  reappear  at  the  next  period  of 
digestion. 

According  to  many  authors,  facial  congestion  is  connected 
with,  and  reciprocal  to,  seborrhoea  of  the  face.  I  believe  the  two 
conditions  to  be  distinct.  But  permanent  congestion  of  the  face 
may  render  a  previous  seborrhoea  more  visible  and  accentuated. 

First  of  all  the  gastric  condition,  which  is  usually  hyperacid, 
must  be  treated  by  alkalis  :  bicarbonate  of  soda,  or  better  car- 
bonate of  lime  in  a  pastille  of  2  grains,  taken  every  hour 
during  gastric  digestion.  If  there  is  constipation  the  carbonate 
of  lime  may  be  replaced  by  similar  pastilles  of  magnesia.  This 
simple  treatment  is  often  followed  by  excellent  results.  If  this 
fails,  a  glass  of  warm  vichy  water  may  be  taken  half  an  hour 
before  each  meal. 


i8 


THE    FACE. 


Local  facial  congestion.  Chilblain.  We  shall  meet  with  these 
conditions  in  studying  the  dermatoses  of  each  region  of  the  face, 
e.  g.,  chilblain  of  the  nose  and  ear.  Many  authors  still  regard 
these  morbid  types  as  the  first  degree  of  cutaneous  disorders, 
labelled  together  formerly  under  the  name  of  lymphatism,  because 
one  especially  of  these  forms,  erythema  pernio,  is  confined  to  ©ne 
of  the  forms  of  lupus  erythematosus  which  we  shall  study, — 
lupus  erythematosus  with  non-cicatricial  evolution. 

LUPUS  ERYTHEMATOSUS. 


Lupus  erythematosus  is  related  to  tuberculosis,  without  the 
lesions  revealing  the  tubercle  bacillus.     The  coexistence  of  lupus 

erythem  a  t  o  s  u  s 
with  the  tuber- 
culides in  general 
and  lupus  vul- 
garis is  not  very 
common,  but  its 
relation  to  tuber- 
culosis is  never- 
t  h  e  1  ess  certain. 
Thus  we  may  see 
on  the  same  sub- 
ject tuberculous 
u  1  c  e  r  a  tions  of 
glandular  origin, 
tuberculous  lupus 
dis  seminated 
round  the  cica- 
trices, resulting  in 
direct  inoculation 
of  the  skin  with 
pus,  and  numer- 
ous patches  of 
lupus  erythemato- 
sus of  the  face 
and  body. 

Lupus      ervthe- 

Flg.    C.       Lupus    erythematosus.  - 

(E.  Besnier'a  patient.     St.  Louis  Hosp.  Museum,   No.   635.)      fn  a  t  O  S  U  S        mav 


THE    FACE.  19 

begin  at  all  ages,  and  its  symptoms  vary  little.  It  forms  red 
patches  of  irregular  form,  depressed,  and  covered  with  white 
adherent  scaly  squames  (cretaceous  herpes  of  Devergie)  ;  the 
patches  being  sensible  to  percussion  {Bcsnier). 

These  patches  may  be  situated  anywhere ;  on  the  nose,  cheeks, 
beard,  forehead,  scalp,  neck,  and  more  rarely  on  the  hands, 
fingers  and  body.  Some  of  the  patches  are  about  half  an  inch 
in  diameter,  others  as  large  as  the  hand.  Their  margin  is  always 
sharply  defined  and  nearly  always  irregular. 

One  form  only  is  symmetrical,  affecting  both  sides  of  the  nose, 
and  known  by  the  name  Vcspertilio.  This  form  is  often  juvenile 
and  superseborrhoeic.  On  the  surface  of  the  patches  appear  the 
dilated  orifices  of  the  sebaceous  glands,  filled  with  an  adherent 
epidermic  cone;  a  condition  known  as  congestive  seborrhoea 
{Casenave).  These  non-atrophic,  non-depressed  erythematous 
patches,  sometimes  change  their  position,  and  may  disappear 
without  leaving  any  traces. 

Lupus  erythematosus  in  its  classic  form,  with  depressed 
patches,  extends,  but  scarcely  ever  retrogresses.  Usually  the 
lesions  remain  unchanged  for  years,  or  heal  on  one  side  by  a 
cicatrix  while  they  develop  on  the  other.  The  cicatrix  in  hairy 
regions  is  completely  alopecic. 

This  affection  is  very  rebellious  and  the  strongest  measures  in 
treatment  give  only  indifferent  results.  Thus,  salicylic  and  pyro- 
gallic  plasters ;  the  galvano-cautery  and  scarifications,  have  much 
less  effect  in  lupus  erythematosus  than  in  tuberculous  lupus. 
The  same  with  Finsen's  phototherapy. 

High  frequency  currents  have  been  tried  without  satisfactory 
results.  Treatment  by  the  X-rays  appears  to  have  the  most 
likely  future.  The  application  of  6  to  10  units  has  caused  a 
radio-dermatitis  with  scarring  which  took  3  to  5  months  to  heal, 
but  which  cured  the  lupus.  Some  authors  think  that  a  slower 
and  less  violent  treatment  gives  the  same  result  (5  or  6  sittings 
of  5  units  H.  with  intervals  of  18  to  20  days).  The  latter  method, 
being  without  inconvenience,  should  be  preferred  at  present,  but 
the  former  method  is  certainly  more  rapid  and  perhaps  more  con- 
stant in  results. 

In  favourable  cases  the  lesion  retrogresses,  the  redness  fades, 
and  is  replaced  by  a  smooth  white  scar. 


20 


THE  FACE. 
TUBERCULOUS  LUPUS. 


Tuberculous  lupus  is  one  of  the  most  severe  dermatoses  which 
affects  the  face.  It  may  occur  in  all  regions  of  the  body,  but  is 
more  frequent  on  the  face  than  elsewhere;  and  more  commonly 
on  or  around  the  nose.  It  consists  in  a  dermic  and  hypodermic 
nodular  tuberculosis.  Inoculation  of  these  nodules  on  the  peri- 
toneum of  the  guinea-pig  causes  typical  peritoneal  tuberculosis. 


i-i«.   8.      Tuberculous    non-ulcerative    lupus.      (Sabouraud's   patient.     Photo    by    Nolr4.) 

The  lesion,  whatever  its  situation,  arises  at  first  as  a  diffuse 
red  patch,  with  a  glazed  surface  and  soft  consistence.  Through 
this  may  be  seen  lupus  nodules;  each  of  the  size  of  millet  seed- 


THE   FACE.  21 

more  or  less  distinct  from  each  other ;  of  a  yellowish  red,  or 
barley  sugar  colour;  and  enclosed  in  the  lesion. 

The  lesion  extends  in  the  dermis  and  under  the  epidermis  (first 
stage,  Fig.  9)  ;  often  ulcerating  with  hypertrophy  of  fungosities 
(second  stage)  ;  later  on  with  progressive  necrosis  (third  stage). 
These  three  processes  may  be  united  in  cases  where  the  evolution 
is  rapid. 

Tuberculous  lupus  is  a  disease  which  is  rarely  fatal  (by  exten- 
sion to  the  mucous  membrane  of  the  nasal  fossae,  the  gums, 
pharynx  and  larynx,  with  concomitant  pulmonary  tuberculosis), 
but  which  in  most  cases  lasts  during  the  patient's  life.  When 
left  to  itself,  or  badly  treated,  which  is  the  rule,  it  ends  in  ulcer- 
ation and  extensive  destruction  of  the  bones  (Fig.  34).  When 
well  treated  it  leaves  cicatrices  of  the  same  dimensions  as  the 
lesions,  which  assume  the  bony  form  of  the  region,  on  account  of 
the  disappearance  of  the  soft  parts. 

The  cicatrices,  according  to  their  situation,  may  lead  to  buccal 
or  nasal  atresia,  or  ectropion  of  the  eyelids  with  consecutive 
chronic  keratitis  and  corneal  opacities. 

The  treatment  of  tuberculous  lupus,  to  be  successful,  should  be 
commenced  at  once,  when  the  lesion  does  not  exceed  the  size  of  a 
sixpence.  It  is  difficult  to  induce  the  patient  or  the  parents  to  agree 
to  total  excision,  owing  to  the  situation  of  the  lesion  on  the  face. 
Excision,  in  order  to  give  good  results,  must  be  as  extensive  and  as 
deep  as  possible.  Most  excisions  are  insufficient  and  lupus  nodules 
generally  reappear  in  the  cicatrix. 

The  application  of  Finsen's  phototherapy  is  the  method  to  be 
preferred.  It  gives,  slowly  but  surely,  perfect  results ;  and,  when 
the  treatment  is  sufficiently  continued,  the  results  are  permanent. 

This  treatment  requires  elaborate  and  expensive  installation.  A 
Voltaic  Arc  of  70  to  80  amperes  is  necessary.  The  light  rays,  emitted 
from  this  source,  are  collected  by  a  series  of  rock  crystal  lenses 
mounted  in  metallic  tubes  and  separated  by  running  water,  eliminat- 
ing all  the  heat  rays.  In  the  focus  of  the  last  lens  is  placed  the 
lesion,  under  a  crystal  compressor  in  which  circulates  a  current  of 
cold  water.  The  object  of  the  compressor  is  to  diminish  the  circu- 
lation of  blood  in  the  lesion  to  be  treated ;  for  the  red  tissues  arrest 
part  of  the  chemical  rays.  Two  days  after  an  application  lasting 
half  an  hour,  a  phlyctenule  forms  which  opens  and  dries  up.  The 
whole  lesion  undergoes  an  inflammatory  process  which  lasts  about 


i2  THE   FACE. 

fifteen  days,  and  when  this  process  subsides  it  leaves  the  lupoid 
lesion  attenuated. 

The  method  of  Finsen  has  been  applied  to  lupus  of  considerable 
dimensions,  but  as  the  number  of  sittings  on  the  same  part  is  also 
considerable  (5  to  15),  and  as  the  part  treated  each  time  cannot 
exceed  an  inch  in  diameter,  the  results  are  extremely  slow. 

We  must  also  mention  those  of  the  older  methods  which  gave 
the  most  satisfactory  results  before  phototherapy.  These  still  remain 
too  often  the  only  ones  which  are  made  use  of. 

Chemical  Caustics.  Vienna  paste,  half  strength,  applied  for 
ten  minutes,  gives  excellent  results.  The  application,  it  is  true, 
causes  considerable  pain.  A  black  scar,  7  to  10  millimetres  in 
thickness,  is  formed,  which  separates  slowly,  leaving  a  smooth 
cicatrix.  Much  progress  is  thus  made  in  a  short  time.  Cauter- 
isation with  pure  permanganate  of  potash  has  given  appreciable 
results  in  ulcerative  lupus. 

Galvano-cautery.  Cauterisation  of  tuberculous  nodules  with 
the  point  of  a  galvano-cautery,  repeated  every  month  on  the  same 
surface,  afterwards  increasing  the  intervals  to  every  two,  three  or 
four  months,  gives  very  good  results,  but  is  nearly  always  incom- 
plete. Later  on  tuberculous  nodules  reappear  in  the  cicatrix 
which  require  destruction  afresh. 

Linear  quadrilateral  scarification  is  useful  to  reduce  the  fungosi- 
ties  of  the  second  stage  of  lupus,  but  should  only  be  employed  in 
tuberculous  lupus  at  the  beginning  of  the  treatment  or  to  correct 
unsightly  cicatrices. 

Ulcerated  fungous  lupus,  tuberculous  fistulae  and  lupus  of  mucous 
membranes  may  be  treated  by  double  cauterisation  (i)  with  nitrate 
of  silver.  (2)  with  metallic  zinc  which  reduces  the  silver  and  sets 
free  nitric  acid.  The  method  is  somewhat  painful,  but  gives  excel- 
lent results. 

Lupus  of  mucous  membranes  is  modified  by  applications  of  pure 
lactic  acid,  chloride  of  zinc  (10  per  cent.),  etc.,  by  repeated  applica- 
tions with  absorbent  wool  pledgets. 

The  accessory  treatment  of  lupus  will  be  considered  more  in 
detail  with  each  localisation  of  the  disease. 

SECONDARY  SYPHILIS. 

Syphilitic  roseola  is  rarely  visible  on  the  face.  The  secondary 
characteristic  eruption  in  this  situation  is  the  papular    (fig.  230). 


THE    FACE. 


23 


This  is  more  or  less  abundant  and  florid,  constituted  by  small  pro- 
jecting round  papules  of  a  brownish  red  colour,  equally  distributed 
and  covering  the  chin,  forehead,  cheeks  and  eyelids.  This  eruption 
occurs  usually  six  weeks  or  two  months  after  the  initial  lesion,  traces 
of  which  with  the  satellite  glands  are  always  easy  to  discover.  The 
eruption  may  precede  the  mucous  patches  by  a  few  days,  or  coincide 
with  them  (vide  Throat).  For  the  general  history  of  syphilis  and 
its  treatment  see  page  644. 

LEPROSY. 

Leprosy  does  not  occur  in  our  country  in  the  florid  tubercular 
form  represented  in  the  figure.    But  in  many  of  our  possessions  in 

Asia  or  America  it 
exists  in  an  endemic 
state,  and  our  sol- 
diers, colonial  ad- 
ministrators and  col- 
onists often  contract 
it  there. 

It  is  a  tubercular 
disease  closely  allied 
to  tuberculosis  and 
caused  by  a  bacil- 
lus morphologically 
very  similar  to  the 
bacillus  of  Koch 
(bacillus  of  Han- 
sen). Up  to  the 
present  the  disease 
is  only  inoculable 
and  contagious  in 
the    human    species. 

On  the  face  it  be- 
gins by  the  forma- 
tion of  projecting 
nodosities  on  the 
eyebrows ;  soft  tu- 
berosities which 
rarely  ulcerate,  but 
rig.  10.    Leontias  ic  lepros.v.    .  nearlv  alwavs  cause 

(Jeanselme's    patient.      Photo    by    Noire.)  -  ^ 


24  THE    FACE. 

almost  complete  alopecia  of  the  eyebrows.  This  alopecia,  which 
sometimes  also  affects  the  moustache  and  beard,  usually  spares  the 
scalp.  The  forehead,  cheeks,  chin  and  nose  gradually  become  infil- 
trated, and  the  features  become  enlarged  and  deformed  by  the  pro- 
duction of  fresh  nodosities  disseminated  over  all  parts  of  the  skin 
(leprous  tubercles).  This  results  in  a  special  leonine  facies  which 
has  given  rise  to  the  word — leonfiasis.  The  tubercles  may  become 
indurated  and  disappear  incompletely.  This  evolution  is  only 
observed  in  France,  where  exotic  leprosy  undergoes  generally  a 
spontaneous  retrogression. 

The  tubercules  often  form  indolent  ulcers  which  may  remain 
stationary  for  years  or  slowly  increase  in  size.  Finally,  attacks  of 
acute  lymphangitis  may  occur,  analogous  to  erysipelas,  after  which 
the  tissues  remain  engorged. 

There  is  no  specific  treatment  for  leprosy,  and  in  the  great 
majority  of  cases  it  is  incurable.  The  local  action  of  X-rays  and 
phototherapy  may  be  tried  methodically,  for  the  action  of  external 
applications  is  scarcely  appreciable.  Apart  from  these  methods  the 
leprous  ulcers  should  be  treated  like  all  atonic  ulcers.  (See  for 
example  p.  307). 

Naphthol  B  taken  internally  in  a  dose  of  30  to  60  grains  and  oil 
of  Chaulmoogra  (Gynocardia  odorata.  Bixacees),  in  the  doses  of 
50  to  200  drops  a  day,  have  caused  certain  improvement,  although 
incomplete.  But  these  drugs,  which  are  often  badly  tolerated  by 
the  stomach,  must  be  taken  in  massive  doses  and  for  a  long  time 
to  have  any  effective  action, 

ERYSIPELAS    OF    THE    FACE. 

Erysipelas  of  the  centre  of  the  face,  the  most  common  form, 
may  begin  m  the  nasal  furrow,  at  the  mternal  angle  of  the  eye,  on 
the  upper  lip,  or  sometimes  in  the  centre  of  the  cheek,  by  a  redness 
which  increases  rapidly  in  intensity  and  extent.  It  is  often  preceded 
by  general  phenomena;  fever,  nausea,  headache,  and  sore  throat. 
These  general  phenomena,  especially  fever,  are  of  sudden  onset. 
The  temperature  rises  to  40°  C.  or  more,  and  remains  so  during  the 
duration  of  the  disease.  There  is  often  delirium,  especially  in  alco- 
holic subjects. 

The  erysipelatous  skin  is  glossy,  red,  tense,  painful,  and  limited 
by  a  sharply  defined  raised  border.     The  region  affected  may  be 


THE    FACE.  25 

extensive  and  may  include  the  whole  of  the  face  and  scalp.  More 
commonly  the  erysipelas  migrates,  the  redness  disappearing  in  the 
part  first  aiTected  and  extending  to  other  parts  (ambulatory  erysip- 
elas). The  temperature  falls  abruptly  on  the  sixth  or  ninth  day,  all 
the  general  and  local  symptoms  subside,  and  cure  takes  place  rapidly 
without  convalescence.  This  description  applies  to  a  case  of  medium 
severity,  but  some  cases  are  more  severe.  Erysipelas  may  be 
phlyctenular,  purulent,  or  more  rarely  gangrenous.  It  may  pre- 
sent all  the  complications  affecting  the  heart,  kidney  and  pleura, 
etc.,  which  occur  in  infective  diseases:  but  resolution  is  always 
the  rule. 

Treatment  is  symptomatic,  both  general  and  local.  The  general 
temperature  may  be  lowered  by  quinine,  antipyrine  and  the  like, 
and  the  local  temperature  by  moist  dressings.  Colloidal  Silver  may 
be  tried  as  a  local  application. 


FOLLICULAR    PSOROSPERMOSIS. 

This  name  is  given,  after  the  researches  of  Darier,  to  a  disease 
which  is  usually  superseborrhoeic,  having  the  regional  seats  of  elec- 
tion of  seborrhoea,  and  characterised  by  brown  conical  crusts 
enclosed  in  greatly  dilated  sebaceous  orifices,  and  each  raised  on  a 
soft  papular  projection. 

This  disease,  the  coccidial  nature  of  which  is  disputed,  but  the 
parasitic  nature  of  which  is  probable,  always  commences  on  the 
face  in  the  nasal  furrows,  the  fold  of  the  chin,  the  nose,  the  glabel- 
lum  and  the  region  under  the  eyebrows.  At  the  same  time  all  the 
seborrhoeic  regions  of  the  body  are  invaded  by  the  same  process ;  the 
mid-thorax,  the  axillae  and  the  groins. 

The  elementary  lesion  is  everywhere  the  same,  but  the  subjacent 
papular  eminences  with  follicular  crusts  may  become  confluent. 

The  disease  is  chronic  and  may  occur  at  any  age,  but  most  often 
in  adolescents  of  the  poorer  classes,  who  neglect  the  elementary 
principles  of  hygiene.  We  shall  have  occasion  to  refer  to  it  again 
with  each  of  the  chief  localisations  of  the  disease. 

The  treatment  is  that  of  seborrhoeic  lesions,  and  consists  in  the 
external  application  of  sulphur,  tar  and  reducing  agents.  Internal 
treatment  is  not  required. 


26  THE    FACE. 

STRONG   OINTMENT. 


aa.  I  gramme     aa.  gr.  i6 


Precipitated    sulphur      .    . 

Salicylic    acid 

Ichthyol      

Cinnabar      

Oil   of  cade lo  grammes  3iii 

Lanoline 30  3j 

WEAK   OINTMENT. 


-aa.  I  gramme    aa.  gr.  24 


Resorcine 

Ichthyol       

Oil  of  birch 

Yellow   oxide   of   mercury    .  J 

Oil   of   cade 10  grammes  3iv 

Lanoline       20  "  5J 

Soaps  are  useful  as  keratolytics,  and  baths  indispensable.  The 
results  of  treatment  are  variable,  but  usually  good  when  the  patient 
takes  some  care  in  carrying  it  out.  But  the  lesions  are  rather 
effaced  than  destroyed,  and  reappear  when  treatment  is  discontinued. 


CHLOASMA. 

Chloasma  consists  in  a  brown  pigmentation  of  the  forehead  and 
temples,  which  appears  in  the  course  of  pregnancy,  sometimes  from 
the  beginning,  and  fades  more  or  less  completely  after  delivery. 

This  "mask"  occupies  symmetrically  the  forehead  and  temples, 
sometimes  the  cheeks,  the  areola  of  the  breasts,  the  labia  majora 
and  the  axial  line  of  the  abdomen. 

On  the  forehead  the  patches  stop  at  the  border  of  the  hairs  by 
a  sharp  and  sinuous  margin.  On  the  temple  they  form  irregular 
but  symmetrical  placards,  usually  yellow  and  very  unsightly. 

Chloasma,  which  is  habitually  connected  with  pregnancy,  may  be 
produced  in  all  peri-uterine  and  peri-renal  diseases,  which  affect 
the  sympathetic  plexus  around  the  supra-renal  capsules. 

The  treatment  is  the  same  as  for  ephelides  (p.  6).  but  it  is  subject 
to  the  same  failures,  and  if  the  cause  persists  or  recurs,  the  chloas- 
mic  patches  also  persist  or  recur. 


THE    FACE. 
VITILIGO. 


27 


The  name  vitiligo  is  given  to  a  non-congenital  dermatosis  char- 
acterised by  the  formation  of  white  patches  with  well  defined  bor- 
ders, surrounded  by  a  zone  of 
pigmentary  hyperchromia.  The 
cause  of  vitiligo  is  unknown;  it 
occurs  after  severe  nervous 
shocks,  or  among  nervous  sub- 
jects, degenerates,  syphilitics  or 
heredo-syphilitics.  It  develops 
insidiously  without  any  subjec- 
tive symptom.  The  patches  pre- 
sent no  anomaly  except  their 
colour.  The  skin  is  normal  to 
the  touch  and  folds  in  the  same 
way  as  normal  skin.  The  col- 
our is  milky-white.  These 
patches,  large  or  small,  sym- 
metrical or  otherwise,  have 
always  clear,  irregular  sinuous 
margins.  Around  each  patch 
the  hyperpigmentation  is  evi- 
dent and  diminishes  insensibly 
till  it  joins  the  normal  skin. 

When  the  vitiliginous  patches 
occupy  or  encroach  on  a  hairy 
region,  the  hairs  are  silvery 
Their  number   on   the  patch   is 

sometimes  only  half  that  on  the  parts  around. 

The    patches    of    vitiligo    differ    from   the    achromic   patches    of 

leprosy  (p.  655)  in  having  no  sensory  affections;  thermic  algesic  or 

tactile. 

The  seat  of  election  of  vitiligo  is  the  face  and  neck,  especially 

the  lateral  parts ;  also  the  back  of  the  hands  and  wrists,  and  the 

genital  organs  (p.  461)  ;  but  it  may  occur  on  all  parts  of  the  body. 

Usually    the    patches    do    not    remain    stationary,    but    increase    or 

decrease,  and  alter  in  position  ;  but  these  changes  occupy  some  years. 
Vitiligo  has  certain,  but  not  definite,  relations  with  alopecia  areata, 

with  sclerodermia  in  patches  or  morphoea,  with  syphilis  and  with 


Fig.  11.     Vitiligo    of    the    face. 

(Lalller's     patient.     St       Louis     Hospital 
Museum,    No.    350.) 


white,   sometimes   even   atrophic. 


28  THE   FACE. 

tabes.  Local  treatment  is  nil.  General  treatment  may  be  instituted 
after  a  complete  examination  of  the  patient  with  regard  to  his 
nervous  system,  heredity  and  former  ailments.  When  there  has 
been  anterior  syphilis,  mercurial  treatment  is  indicated. 

"It  is  probable  that  ovarian,  thyroid,  orchitic  or  supra-renal 
opotherapy,  according  to  the  condition  of  the  patient,  may  be  called 
into  play"  in  the  treatment  of  vitiligo.     (Darter). 

ARTIFICIAL    DERMATITIS. 

The  face,  hands  and  wrists,  the  feet  and  ankles,  have  a  certain 
number  of  dermatoses  in  common.     The  traumatic  dermatoses  due 


Fig.  12.     Artificial   dermatitis    due   to   the   application   of  a   dye. 
(Brocq's    patient.      Photo    by    Sottas.) 

to  the  irritant  action  of  external  agents  are  particularly  common 
on  the  hands  and  face. 


THE    FACE.  29 

On  the  face  they  have  two  common  causes;  the  appHcation  of 
irritating  ointments  (sulphur,  salol,  etc.)  ;  or  hair  dyes  containing 
substances  which  have  a  toxic  action  on  certain  skins ;  the  most 
common  of  which  is  paraphenyl  diamine.  The  appearance  of  these 
lesions  is  that  of  a  sub-acute  eczema,  total  or  in  patches,  and  situ- 
ated most  often  on  the  forehead,  ears,  nose  and  lips.  The  horny 
epidermis  is  raised  by  myriads  of  miliary  vesicles  close  together,  the 
surface  of  the  skin  having  a  finely  mammillated  appearance.  Each 
vesicle  contains  a  small  drop  of  turbid  fluid.  These  lesions  are 
always  accompanied  by  a  considerably  degree  of  diffuse  oedema, 
which  causes  swelling  of  the  loose  tissues  of  the  eyelids,  neck,  etc. 

In  a  more  accentuated  form  the  vesicles  are  ruptured,  and  exuda- 
tions occur  in  the  situation  of  each  (the  punctate  perforations  of 
Devergie).  The  exudation  may  be  slight  or  considerable,  and  may 
form  a  thin  placard  of  adherent,  honey-like  crust.  This  acute  phase 
usually  lasts  only  if  the  cause  of  the  irritation  is  renewed.  If,  on 
the  other  hand,  the  exudation  ceases  the  lesion  becomes  dry  and 
desquamating  and  the  skin  gradually  resumes  its  normal  aspect. 

Treatment  consists  in  removal  of  the  cause,  which  includes  not 
only  the  avoidance  of  further  applications  of  the  irritating  agent, 
but  also  removal  of  the  traces  of  it  which  remain.  Moist  dressings, 
cataplasms  of  potato  starch,  made  while  hot  and  applied  cold ;  and 
washing  with  a  badger  hair  brush  with  a  very  mild  soap  are  useful. 
When  the  epidermis  is  much  injured  pulverisation  with  camomile 
water  or  simple  boiled  water  (not  boric)  is  preferable  to  soap. 

As  soon  as  the  lesions  cease  to  discharge  a  protective  paste  of 
equal  parts  oxide  of  zinc,  lanoline  and  vaseline  gives  an  excellent 
result ;  the  epidermis  being  regenerated  underneath  it.  Benign 
traumatic  dermatitis  lasts  from  3  to  15  days:  more  severe  cases 
may  persist  for  two  months  or  more.  If  the  cure  is  delayed  the 
urine  should  be  examined  and  internal  treatment  adopted,  for 
glycosuria,  hyper-acidity,  hypophosphaturia,  oxaluria,  etc.,  which 
the  analysis  of  the  urine  may  indicate. 


ACNE   ROSACEA. 

Towards  the  fiftieth  year  the  seborrhoeic  and  telangiectasic 
processes,  which  generally  become  attenuated  when  the  adoles- 
cent has  become  adult,  occur  afresh,  and  take  on  another  aspect. 


30 


THE    FACE. 


Venous  stasis  becomes  pronounced ;  the  face  becomes  diffusely 
red  or  purple,  and  the  tissues  thickened ;  the  skin  becomes  coarse 

and  dotted  with  the 
gaping  sebaceous  ori- 
fices.  The  different 
forms  of  polymorphous 
acne  appear  here  and 
there,  pustular,  indur- 
ated and  cystic,  but 
chiefly  the  hypertrophic 
and  congestive  forms 
(see  Rhinophyma,  p. 
103).  This  is  a  syndrome 
which  is  seen  at  its 
maximum  in  the  sub- 
jects of  varicose,  car- 
diac and  cardio-renal 
affections,  and  may  also 
occur  at  the  meno- 
pause in  women. 

In  these  cases  local 
treatment  is  directed 
against  the  elements  of 
polymorphous  acne, 
etc.  (p.  15),  but  gen- 
eral treatment  is  more 
important.  According 
to  the  case,  the  condition  of  the  digestive  tract,  dilatation  of  the 
stomach  and  intestinal  paresis  must  be  looked  for.  In  other  cases 
cardiac  or  renal  troubles  require  appropriate  treatment,  which 
need  not  concern  us  here.  The  result  is  rarely  complete,  but  the 
most  prominent  symptoms  may  be  alleviated.  Local  treatment 
concerns  chiefly  the  elements  of  rosacea  and  hypertrophic  acne. 
This  treatment  consists  especially  in  the  use  of  the  fine  galvano- 
cautery,  especially  in  hypertrophic  acne  of  the  nose,  the  most 
frequent  and  the  most  distressing  form  (p.  103). 

SENILE  WART. 
On   integuments  which   have   undergone  senile   changes   and 
become  telangiectasic,  turgid  and  infiltrated,  a  series  of  morbid 


-"O-- 


Fig.    13.      Acne    rosacea.       (Besnier's    patient. 
Louis    Hosp.   Museum,    No.    563.) 


THE    FACE.  31 

conditions  may  arise  which  must  be  considered  as  parasitic, 
although  this  parasitism  is  not  definite. 

In  places  the  senile  skin  has  an  unwashed  appearance,  covered 
with  a  kind  of  yellow  or  black  scum.  This  is  not  due  to  the 
superposition  of  exuded  fat  but  to  a  velvety  quasi-papillomatous 
transformation  of  the  epidermis.  It  is  a  flat  wart,  wrongly  called 
seborrhoeic  because  it  is  often  superseborrhoeic.  It  is  also  said  to 
be  contagious  because  it  multiplies,  and  inoculation  with  a  pin 
appears  to  transmit  it. 

These  lesions  improve  greatly  under  the  influence  of  reducing 
ointments  containing  chlorates  : — 

Chlorate   of  potash 150   centigrammes     gr.  24 

Precipitated   sulphur     ....     3  grammes  gr.  48 

Resorcine i  gramme  gr.  16 

Vaseline 30  grammes  3i 

It  is  possible  that  in  the  majority  of  cases  temporary  disappear- 
ance is  obtained  rather  than  cure  of  the  lesion.  Epitheliomatous 
transformation  of  these  lesions  is  often  seen,  but  is  not  constant. 

PRE-EPITHELIOMATOUS   SENILE   SEBORRHOEA. 

Of  a  similar  nature  is  the  slow  formation,  in  one  or  more  parts 
of  the  face,  in  the  aged,  of  a  hard,  yellow  crust,  adherent  to  the 
subjacent  skin,  to  which  it  is  fixed  by  numerous  conical  projections 
occupying  the  sebaceous  pores.  Under  this  crust  the  skin  is  not 
quite  normal,  but  its  surface  is  velvety  and  there  is  a  corresponding 
fitting  of  the  projections  of  the  skin  with  those  of  the  crust,  so 
that  removal  of  the  latter  may  cause  bleeding.  The  process  is 
slow,  and  may  continue  for  five  or  six  years  without  the  crust  fall- 
ing.    When  this  is  removed  it  is  quickly  reproduced  (Fig.  14). 

EPITHELIOMA. 

Malignant  epithelioma  of  the  face,  apart  from  the  mouth,  is  rare 
and  usually  develops  on  the  cicatrices  of  former  lupus  (Fig.  15); 
but  benign  epithelioma  is  common. 

It  is  also  a  lesion  of  senility,  occurring,  like  the  preceding,  on 
a  skin  altered  by  seborrhoea  and  telangiectases,  etc.  Sometimes  it 
arises  as  a  small  atonic  ulcer  which  grows  under  a  crust  of  con- 
crete seborrhcea ;  at  other  times  it  is  a  raised  non-ulcerating  lesion 
consisting  of  epidermic  pearls  placed  side  by  side  in  a  circle,  which 


32 


THE    FACE. 


later  on  expands  while  its  centre  becomes  ulcerated.  The  lesion 
rarely  assumes  a  granulating  form,  objectively  neoplastic^  except 
when  the  epithelioma  is  secondary  (Fig.  15). 


Fig.  14.     Pre-epitheliomatous     concrete     lesions     of 

Seborrhoea. 

(Sabouraud's    patient.     Photo    by    Noir6.) 


Ulcerated  epithelioma  may  slowly  increase  in  size  for  years 
without  becoming  malignant,  giving  rise  to  metastasis,  or  alter- 
ing the  general  condition  of  the  patient.  This  slow  evolution  is 
the  rule,  but  sometimes  it  is  otherwise  and  a  chronic  superficial 

*  For  further  details  see  the  article  on  cutaneous  epithelioma,  p.  639. 


THE    FACE. 


33 


ulceration  finally  develops  into  a  cancer.  This  is  the  exception. 
For  benign  epitheliomas  simple  expectation,  curetting,  actual 
cautery,  chemical  destruction,  chlorated  pastes  and  powders,  etc., 
were  formerly  prescribed.  To-day  there  is  only  one  form  of  treat- 
ment which  seems  to  be  of  value  in  nearly  all  cases ;  the  X-rays. 
Usually  six  applications  at  intervals  of  i8  days,  with  5  units  of 
Hohknecht,  or  tint  B  of  the  radiometer  of  Sabonraud  and  Noire; 
are  sufficient.  Even  if  the  lesion  has  disappeared  before  the  last 
application  it  should  be  administered  in  order  to  prevent  the 
chance  of  relapse. 


MYCOSIS     FUNGOIDES. 


■Mycosis  fungoides  is  a  generalised  dermatosis  which  will  be 
considered  later  on  (p.  637). 


^0rm 


%^U 


Fig.    15.      Epithelioma    aeveloping    in    former    lupus. 
(Besnier's    patient.      St.    Louis    Hosp.    Museum.) 


When  fully  developed  mycosis  fungoides  nearly  always  affects 
the  face,  causing  diffuse  infiltration  and  swellings,  shown  very 
w^ell  in   Figure    18.     This  aspect  is  characteristic,  as  well  as  the. 


34 


THE    FACE. 


slow  evolution  of  the  diease,  which  is  for  a  long  time  compatible 
with  comparatively  good  health. 


PERNICIOUS   LYMPHADENIA. 

In  pernicious  lymphadenia,  another  analogous  generalised  der- 
matosis, erythodermia  is  more  diffuse  and  the  tissues  are  i«- 


Fig.  16.     Ulcerated     epitheHoma     of    the        Fig.  17.     The  same   cured  by  X-rays, 
face. 
(Sabouraud's   Datlent      Photo   by    Noir4.) 


filtrated  and  thickened  en  masse  without  forming  distinct 
tumours,  A  comparison  of  the  two  figures  will  convey  a  better 
idea  than  any  description.  The  general  history  of  the  disease  is 
described  on  p.  639. 


THE    FACE. 


3S 


Fig.    18.      Mycosis    fungoides. 
(Hallopeau's    patient.      St.    Louis    Hospital    Museum.      No.     1706.> 


Fig.    19.      Cutaneous    Lymphadenia. 
(Hallopeau's   patient.      St.    Louis   Hospital   Museum,   No.    1964.) 


THE    MOUTH. 

In  a  series  of  separate  chapters  I  propose  to  study  later  on  the 
dermatoses  having  their  seats  of  election  in  the  tongue,  the  gums, 
the  checks,  and  the  throat,  but  I  shall  first  devote  a  few  pages  to 
affections  which  may  occur  in  the  mouth,  without  having  any 
evident  predilection  for  any  one  of  its  parts. 


Among  these  I  shall  first  consider  ulcero-ineni-] 

Iranous  stomatitis,  the  name  of  zi'hich  sufticicnt'x  r     _ 

.   J-     ,        •,       ,          ,  Stomatitis     ...   p.  37 

f.idicates   its   characters J  '    "' 

.    .    .    Then   the  at'hthous  stomatitis  of  a«;;»fl/.y,'l  Aphthous    Stomati- 
7i'hich  in  rare  cases  may  develop  in  the  child  .    .    .J      tis P- 37 

.    .    .  and   Simple  aphthae;    small,    common    i»- 1 
flammatory   lesions,  ivhich   must  be   carefully  dis-  i-  Simple      Aphth?e   .   p.  38 
tnigiiished  from  the  preceding J 

Mercurial  stomatitis  has  the  gums  for  its  point^ 
of  origin  and  essential  localisation.     It  zi'ill  there-l^^^^^^^^^^^    Stomati- 
fore  be  dealt  ivith  elsezvhere J       ^^ P-    57 

But  the  stomato-mycosis  of  nurslings  and  cachec- 
iics,  known  under  the  name  of  thrush,  is  usually 
generalised  in  the  whole  mouth,  and  zvill  he 
studied  here 


-Thrush   .    .    .    .    .p.    38 


Simple  leucoplasia  may  affect  the  n'hole  mouth 
ivith  disseminated  white  patches.  It  therefore  be- 
longs to  this  chapter 


Simple     leucoplasia  p.  39 


The  same  with  lupus  of  the  mouth,  papillomatous] 
and  ulcerative  forms  of  which   may  occur  on   the  j  Tuberculous     lupus  p.  41 
palate,  gums,  cheeks  and  lips J 

Lupus  erythematosus  is  seldom  seen  except  o;n  Lupus  Erythemato- 
the  cheeks  and  will  be  studied  with  them   ....         sus P-  74 

.    .    .    The  same  zvith   lichen  planus Lichen  planus   .    .   p.    y^^ 

I  shall  say  a  few  words  concerning  .-Ica«//io.sj'.sl  Acanthosis       nigri- 
iiigricans J      cans p.  4^ 

.    .    .  Melanodermia Melanodermia    .     .    p.  42 

-    .    .  and  Vitiligo Vitiligo      p.  42 


THE    AIOUTH  37 

ULCERO-MEMBRANOUS   STOMATITIS. 

Ulcero-membranous  stomatitis  is  contagious  and  epidemic  and 
especially  attacks  children  of  three  to  eight  years;  but  it  may 
be  observed  at  any  age. 

It  is  characterised  at  first  by  extreme  dysphagia  accompanied 
by  salivation  and  an  offensive  odour  from  the  mouth.  On  dif- 
ferent parts  of  the  internal  surface  of  the  cheeks,  the  floor  of  the 
mouth  and  borders  of  the  tongue  are  seen  thick  patches  of  a  yel- 
lowish white,  or  buff  colour.  These  have  a  tendency  to  separate 
at  their  edges,  disclosing  a  sanious  ulceration  which  bleeds  easily. 
The  disease  is  accompanied  by  some  fever  and  malaise  and  lasts 
from  5  to  15  days,  ending  in  resolution,  which  is  always  much 
accelerated  by  treatment. 

Treatment.  All  the  patches  should  be  frequently  toviched 
with  a  brush  charged  with  a  5  per  cent,  solution  of  chloride  of 
lime.  Camphorated  ether  or  chlorate  of  potash  may  be  also  used, 
but  chloride  of  lime  is  the  best. 

The  microbial  origin  of  ulcero-membranous  stomatitis  is 
obvious,  but  the  specific  microbe  has  not  been  isolated.  It  some- 
times, but  not  always,  shows  the  presence  of  the  bacillus  of  Jln- 
ccnt.  In  this  case  it  is  accompanied  by  the  ulcerative  and  mem- 
branous angina  of  the  same  type. 

APHTHOUS    STOMATITIS. 

Aphthous  stomatitis  is  a  bovine  disease  which  may  be  inocu- 
lated in  man.  This  is  rare,  and  the  resulting  affection  is  usually 
benign.  It  may  exceptionally  assume  a  severe  form  in  the  nurs- 
ling and  end  fatally.  It  is  always  accompanied  by  malaise,  fever, 
gastric  disorder,  enteritis  and  prostration. 

The  mouth  is  filled  with  minute  ulcerations  situated  chiefly  at 
the  back  of  the  throat,  each  of  which  resembles  exactly  a  simple 
aphtha.  There  is  dysphagia  and  salivation.  Local  treatment  is 
almost  nil ;  painting  with  lemon  juice,  etc.  General  treatment 
is  not  much  use,  but  in  the  nursling  small  doses  of  calomel  may 
be  given. 

The  milk  of  cows  affected  with  aphthous  fever  may  be  con- 
sumed by  the  infant  on  condition  of  its  being  boiled.     (Nocard). 


THE    MOUTH. 


APHTHAE. 


Simple  aphthse  have  nothing  in  common  with  aphthous  fever. 
They  are  small  common  lesions,  which  appear  to  have  no  specific 
mature,  which  arise  without  definite  cause  in  crops;  one,  two  or 
Ihree  at  a  time,  on  the  tongue,  gums  or  lips. 

They  first  appear  in  the  form  of  small  pustules  as  large  as  a 
millet  seed,  and  very  sensible  to  every  movement  of  the  tongue 
when  they  occur  on  it,  or  when  it  rubs  them.  The  pustules 
always  open,  so  that  many  authors  who  have  only  observed  the 
lesions  in  this  state  describe  them  as  primary  ulcers.  The  ulcera- 
tion is  small  and  infundibular,  reddish  grey  in  colour,  and  very 
painful  to  all  movements  of  the  tongue.  It  heals  usually  in  six 
or  eight  days  without  treatment.  Aphthae  are  nearly  always  recur- 
rent. Some  persons  have  a  crop  of  two  or  three  lesions  six 
times  a  year;  others  one  or  two  every  year.  The  attacks  may 
coincide  or  not  with  other  lesions,  such  as  tonsillitis  and  gastric 
disorders,  but  may  be  observed  in  apparent  health.  The  aspect 
and  characters  of  aphthae  resemble  herpes,  but  I  regard  them  as 
more  closely  allied  to  the  pustular  impetigo  of  Bockhart  (p.  183). 
However,  the  anatomical  and  bacteriological  proof  of  their  nature 
is  wanting. 

It  is  necessary  to  bear  in  mind  that  the  recurrent  lesions  may 
often  become  the  origin  of  syphilopJwbia  in  neurasthenic  subjects, 
who  always  regard  aphthae  as  the  mucous  patches  of  syphilis. 

Each  aphtha  may  be  cauterised  with  sulphate  of  copper.  Water 
of  St.  Christau  is  useful  as  a  mouth  wash.  In  benign  cases  local 
treatment  may  be  disregarded,  but  it  is  well  to  correct  gastric  or 
hepatic  troubles  which  occur  in  patients  subject  to  recurrent 
aphthae,  and  also  the  salivary  acidity  which  they  often  present. 


THRUSH. 

The  "thrush"  is  a  buccal  mycosis  caused  by  the  proliferation 
of  the  oiDiuM  ALBICANS  in  the  superficial  layers  of  the  epidermis. 
This  affection  is  characterised  by  white,  stellate  spots,  resembling 
hoar  frost,  adherent  to  the  mucous  membrane,  very  slightly 
raised  and  situated  on  the  dorsal  surface  and  borders  of  the 
tongue,  the  gums  and  floor    of    the    mouth.     Thrush    is    only 


THE    MOUTH.  39 

observed  when  the  saHva  is  acid.  In  the  nursling,  contagion 
occurs  from  one  infant  to  another  and  may  thus  affect  a  whole 
nursery ;  but  dyspeptic  infants  are  the  most  often  attacked.  The 
affected  child  sucks  badly  owing  to  suction  being  painful.  The 
nurse  often  mistakes  thrush  for  curds  of  milk  remaining  on  the 
tongue.  Alicroscopic  examination  confirms  the  diagnosis ;  a 
trace  of  the  white  patch  examined  without  staining  in  glycerine 
or  liquor  potassse  showing  a  mycelial  mesh  work  with  rows  of 
spores  at  intervals  among  the  filaments. 

Thrush  in  infants  should  be  treated  with  alkalis  and  local 
applications  of  borate  of  soda.  Vichy  water  may  be  given  either 
mixed  with  the  milk  or  by  a  spoon  before  each  feed. 

Thrush  is  not  always  of  grave  prognosis  in  the  infant  and  may 
often  be  seen  in  slight  gastric  disorders. 

In  the  adult  it  is  not  the  same  and  only  arises  in  states  of 
extreme  cachexia,  especially  in  the  tuberculous ;  in  tuberculous 
peritonitis  its  appearance  is  always  grave.  It  is  moreover  a 
complication  which  is  often  very  distressing  to  the  patient  and 
one  which  requires  treatment  by  itself,  for  it  may  render  the  last 
days  of  dying  patients  painful.  Cocaine  or  stovaine,  in  one  per 
cent,  solution,  should  be  applied  locally,  alternating  with  alkaline 
applications. 

LEUCOPLASIA  (BUCCAL  PSORIASIS). 

According  to  some  authors  all  leucoplasia  is  either  syphilis  or 
lichen  planus.     With  regard  to  lichen  planus  it  will  be  described 

later  on  (p.  73).  Concerning 
syphilis,  it  is  certain  that  the 
relative  number  of  syphilitic  leu- 
coplasias  has  increased  during  the 
last  ten  years,  since  the  tertiary 
lesions  of  syphilis  have  been  more 
attentively  studied.  There  still 
remains,  however,  an  essential 
leucoplasia  which  cannot  be 
regarded  as  syphilitic  in  the 
absence  of  further  information : 
(i)  because    it   occurs  in  a  great 

Fig.  20.     Lingual    Leucoplasia.  nUmbcr   of   pCOpIc   wllO   deny    hav- 

(Lailler's     patient.   St.     Louis  .  ,,  im-  iit 

Hosp.  Museum.  No.  118.)  mg    had    svphilis  and  who  have 


40  .  THE    MOUTH. 

never  presented  anv  recognisable  lesions:  (2)  because  it  is 
observed  in  voting  people  at  an  age  when  acquired  syphilis  can- 
not have  arrived  at  the  tertiary  stage,  and  where  hereditary 
syphilis,  of  which  they  have  no  stigmata,  becomes  rare:  (3) 
because  anatomically  it  consists  of  a  lesion  which  is  primarily 
hyperkeratotic  without  appreciable  vascular  changes,  while  all 
the  known  lesions  of  syphilis  commence  as  a  primary  perivascular 
lesion. 

Simple  leucoplasia  is  not  limited  to  the  tongue,  but  also  occurs, 
inside  the  labial  commissure  in  the  form  of  an  irregular  patch, 
wrinkled  like  a  bird's  claw.  It  may  also  occur  on  the  inner  sur- 
face of  the  cheek,  on  the  gums,  on  the  inner  surface  and  free  bor- 
der of  the  lower  lip.  The  lesion  is  everywhere  the  same,  like  a 
cigarette  paper  stuck  to  the  mucous  membrane  and  intersected 
by  crossed  folds  (parqueted).  On  the  tongue  it  is  less  white 
than  in  other  situations  and  of  a  rose  lilac  hue,  due  to  the  colour 
of  the  tongue  shevving  through  it.  The  villous  surface  of  the 
tongue  is  replaced  by  a  smooth  surface  where  the  mucous  mem- 
brane is  slightly  thickened,  giving  a  sensation  of  india  rubber 
both  to  the  finger  and  the  eye.  The  borders  are  well  defined  and 
often  appear  as  if  cut  by  scissors. 

Leucoplasia  is  a  chronic  hyperkeratosis  of  unknown  origin. 
Among  the  secondary  causes,  the  abuse  of  tobacco  is  certainly  of 
importance,  but  this  cause  may  be  wanting.  Males  are  more 
often  affected  than  females.  It  commences  at  18,  20  or  25  years 
of  age,  but  occasionally  later.  Very  often  after  some  years  it  is 
complicated  with  epithelioma. 

The  treatment  of  this  affection  is  difficult ;  mouth  washes  with 
alkalis  or  cupric  waters  (St.  Christau)  may  be  tried,  but  they 
have  no  real  effect  except  on  the  fissures  and  artificial  irritations 
which  the  lesions  may  present.  Curetting  and  destruction  by  the 
galvano-cautery  have  been  recommended,  but  the  first  method 
which  should  be  attempted  is  radiotherapy.  I  have  had  incom- 
plete but  excellent  results  in  the  only  case  in  which  I  have  tried 
it;  incomplete  because  the  treatment  was  only  applied  to  a  part 
when  epithelioma  had  developed.  The  epithelioma  disappeared 
and  with  it  the  leucoplasia  in  all  the  region  exposed. 

As  a  precept  one  might  say  that,  with  the  exception  of  radio- 
therapy, it  is  better  not  to  touch  a  leucoplasia  than  to  half  treat 


THE    MOUTH. 


41 


it,  for  all  irritation  of  a  leucoplasia  appears  capable  of  provoking 
epithelial  degeneration. 

TUBERCULOUS   LUPUS    OF   THE   MOUTH. 


Lupus  of  the  mouth  is  not  usually  primary,  but  is  produced  by 
extension  of  a  lupus  of  nasa^l  origin  to  the  lips  and  gums. 

On  the  mucous  membrane  it 
may  affect  an  ulcerative  form, 
but  is  more  often  papillomatous, 
with  scattered  points  of  necrosis. 
Lupus  in  placards  invades  espe- 
cially the  gums  and  then  the 
floor  of  the  mouth  and  palate 
and  even  the  inner  surface  of 
the  cheeks.  It  forms  at  first  a 
hypertrophy  of  the  mucous 
membrane  followed  by  points  of 
necrosis,  denuding  the  teeth  till 
they  sometimes  fall  out.  The 
lesion  is  friable,  very  slowly 
extensive  and  bleeds  easily. 
Here  as  elsewhere  it  does  not 
undergo  spontaneous  resolution.  Most  commonly  the  lesions  are 
visible  externally  because  the  lip  has  disappeared  partially  or  totally, 
and  the  buccal  orifice  forms  an  ulcer  of  which  the  base  is  formed  by 
the  denuded  teeth  implanted  in  a  fungating  and  ulcerated  gum. 

In  this  degree  lupus  of  the  mucosa  is  almost  incurable.  Appli- 
cations of  permanganate  of  potash,  pure  lactic  acid  or  chloride  of 
zinc  (i  in  15)  are  excellent  modifying  agents,  but  the  result  depends 
on  the  amount  of  care  taken.  The  patient  must  be  treated  daily 
and  the  drug  applied  to  each  part.  Phototherapy  should  be  applied 
to  every  accessible  part,  especially  the  gums. 


Fig.  21.     Lupus   of   the   nose,    lips  and 

gums.      (Lailler's     patient.     St. 

Louis    Hosp.     Museum,     No. 

228.) 


LUPUS    ERYTHEMATOSUS. 


Lupus  erythematosus  of  the  mouth  is  rare  and  hardly  exists 
except  inside  the  cheeks.  We  shall  consider  it  with  the  diseases  of 
this  region. 


^  THE   MOUTH. 

LICHEN   PLANUS. 

The  same  applies  to  lichen  planus,  which  afifects  the  same  localisa- 
tion, and  is  only  seen  exceptionally  on  the  dorsal  surface  of  the 
tongue  {p.  73)' 

ACANTHOSIS    NIGRICANS. 

This  is  a  dermatosis  which  should  he  included  in  the  group  of 
toxidermias,  being  connected  with  a  cachectic  state,  most  often  can- 
cerous, and  in  most  cases  with  the  development  of  cancer  of  the 
stomach.  Its  maximum  lesions  are  situated  in  the  folds  of  flexion 
and  in  the  mouth. 

In  the  mouth,  the  inside  of  the  cheeks  and  gums  are  the  parts 
most  affected.  The  lesions  have  two  elements,  black  and  diffuse 
hyperpigmentation  and  a  kind  of  smooth  villous  transformation 
of  the  mucosa.  These  lesions  must  be  recognised  in  order  to  make 
a  differential  diagnosis.  In  themselves  they  require  no  treatment 
and  their  prognosis  is  grave  owing  to  the  gravity  of  their  etiology. 

MELANODERMIA.     VITILIGO. 

All  forms  of  melanodermia  may  be  obser\'^ed  in  the  mouth  as  on 
the  skin.  They  are  seen  especially  inside  the  cheeks.  They  com- 
prise:— the  melanodermia  of  Addison's  disease,  i.e.,  cutaneous 
hyperpigmentation  of  the  head  and  hands  connected  with  organic 
lesions  of  the  super-renal  capsules:  the  melanodermia  of  acanthosis 
nigricans  of  which  we  have  just  spoken:  the  melanodermia  of 
xeroderma  pigmentosum  (p.  6):  diabetic  melanodermia:  lastly, 
phtiriasic  melanodermia  of  the  back  (p.  614)  appears  in  the  most 
marked  cases  to  be  accompanied  by  melanodermia  of  the  inside  of 
the  cheeks  (Thibierge). 

\''itiligo  may  occur  on  mucous  membranes.  It  is  seen  especially 
in  the  mouth  and  inside  the  cheeks,  in  concomitance  with  vitiligo 
of  the  skin,  neck  and  cheeks  (p.  27).  It  has  the  same  symptomatol- 
ogy, evolution  and  long  duration.  The  etiology  and  therapeutics 
are  no  more  determined  than  those  of  vitiligo  of  the  skin. 


THE   TONGUE. 

The  dermatology  of  the  tongue  is  extremely  complex  and  diffi- 
cult to  sum  up  in  a  few  pages. 


/  shall  speak  first  of  that  congenital  macroglossia'] 
(Scrotal   tongue)    zvhich   is   often   mistaken   for  o  rMacroglossia 
•disease,  but  which  is  only  a  malformation  .... 

N(evi  and  angiomata,  zvhich  are  also  malformaA 
tions,  zi'ill  occupy  us  next,  for  their  frequent  devcl-  r  Angiomata    . 
■opment  necessitates  active  treatment -^ 

Lymphangiomata,  although  more  rare,  may  re- 
quire treatment 

Children,  more  often  than  adults,  may  present 
on  the  surface  of  the  tongue  segments  of  circles 
diversely  associated  and  constituted  by  an  accumu- 
lation of  liyperkeratotic  epidermis 

At  all  ages  the  tongue  may  present  on  its  bor-^^ 
ders  small  painful  ulcerative  lesions;  aphehae   .     jApntlise 

And  the  white  arborescent  patches  of  thrush  .    .     Thrush 


P-44 


P-45 


Lymphangiomata    .  p.  45 


Exfoliating       mar- 
ginate   glossitis.    . 


P-4S 

p.  46 
p.  46 


There    exists    a    special    hyperkeratosis    of    the'\ 
tongue  and   lips,   formed  by   large,  zvhite,  smooth  h  Non-specific  leuco- 
and  parqueted  patches   (lingual  psoriasis)    .    .    .    .  -^      plasia 

Syphilis  may  occur  on  the  tongue  under  diverse-^ 
forms.     The  initial  lesion  may  also  be  seen  there  _  j ->yP''"''t' 


c  chancre 


Also  mucous  patches;  raised,  smooth  and  ulcer- 
^f^j  !- Mucous     patches   . 

Also  tertiary  glossitis Tertiary   glossitis  . 

Finally,  syphilitic  lucoplasia  and  gummata  .    .    .    Specific   leucoplasia 

A    dental   glossitis    exists Dental  glossitis  .    . 

And  also  traumatic  ulcers  of  the  tongue,  which^, 

may  simulate  syphilitic,   tuberculous   or  cancerous\^^^^^^^^'''      ulcera- 

lesions 


p.  46 
P-47 

P-47 

p.  48 
p.  49 

P-50 
J      tions P-50 


Lingual  tuberculosis  will  be  studied  by  itself  and 
by  comparison  witJi  diverse  lesions  of  the  tongue 
with  which  it  must  not  be  confounded 

Lingual  epithelioma  must  also  be  distinguished' 
from  syphilitic,  tuberculous  and  traumatic  lesions 
which  resemble  it:  for  it  requires  very  different 
treatment 


Lingual 
losis 


tubercu- 


PSi 


Epithelioma 


PSi 


44  THE   TONGUE. 

After  this,  I  shall  say  a  few  words  concerning  lesions  of  relatively 
less  importance: — 


Bullous     Hydroa  .  p.  53 


The  old  bullous  hydroa,  which  should  he  now' 
included  in  the  polymorphous  dermatitis  of 
Dnhring-Brocq -' 

Lichen  planus  of  the  tongue  which  is  naturally^ 
observed  only  in  concomitance  with  lichen  planus  r  Lichen     planus   .    .  p.  53 
of  the  inner  surface  of  the  cheek -' 

The  black  villous  tongue  frequently  seen  in  old^ 
.     . »         .  •     7      u  ..  ;        J        7  r  Black  tongue  .    .   .  p.  S3 

people  and  m  hospitals  and  asylums J  ^  *^  •'*' 

The  painful  tongue  of  the  neurotic;  glossodynia 
and  painful  papillitis,  zi'hich  belong  more  to  nervous  \G\ossodynia.      .    .   .  p.  54 
pathology   than   to   dermatology ■  .    .    .J 

Finally,  traumatic  ulceration  of  the  fraenum  o^  Ulceration  of  frae- 
the  tongue J      num p.  54 


MACROGLOSSIA      (SCROTAL  TONGUE). 

This  is  a  congenital  malformation  consisting  in  irregular  parallel 
longitudinal  folds,  giving  the  tongue  the  wrinkled  aspect  of  the 
scrotum.  These  folds  are,  in  fact,  fissures  covered  with  epidermis, 
not  painful  and  not  resulting  from  any  morbid  process.  According 
to  some  authors  they  result  from  folding  of  the  tongue  owing  to 
its  being  too  large  for  the  mouth :  according  to  others  it  is  a  primary 
anomaly  of  the  muscle,  on  the  form  of  which  the  mucosa  becomes 
moulded.  In  any  case  this  condition  requires  no  treatment  except 
hygienic  precautions  for  cleansing  the  mouth  and  the  depths  of  the 
folds. 

Chlorate  of  potash 2  parts 

Soap 10      " 

Prepared  chalk 10      " 

Menthol i  part 

Precautions  should  be  increased  if  the  patient  contracts  a  buccal 
disease,  or  a  general  disease  such  as  syphilis  having  a  tendency  to 
cause  lesions  of  the  tongue. 

In  practice  the  importance  is  not  to  confound  this  malformation 
with  acquired  lesions,  particularly  with  syphilitic  tertiary  rhagades, 
which  would  be  a  grievous  error. 


THE    TONGUE.  45 

ANGIOMATA. 

These  develop  rarely  in  the  adult,  but  are  seen  in  the  child  and 
adolescent.  They  usually  occur  in  the  form  of  a  soft  oblong  tumour 
disappearing  under  compression.  These  tumours  have  the  colour 
of  the  mucous  membrane  if  the  angioma  is  situated  deeply ;  violet  or 
blue  if  the  colour  of  the  veins  shews  through  the  mucosa.  They 
are  na:z'i  with  a  possible  progressive  development  and  require  treat- 
ment only  when  they  increase  in  size.  This  consists  either  in  uni-  or 
bipolar  electrolysis  (p.  5),  or  excision;  according  to  the  nature  and 
accessibility  of  the  tumour. 

LYMPHANGIOMATA. 

Lymphangioma  of  the  tongue  usually  has  the  following  appear- 
ance. In  its  anterior  third,  and  not  quite  symmetrically,  the  tongue 
is  increased  in  thickness,  its  surface  is  yellow  and  folded  irregu- 
larly in  its  length.  On  the  yellow,  almost  linear  folds,  the  dissem- 
inated papillae  form  small  red  projections  on  the  yellow  base  of  the 
tumour.  Puncture  of  the  yellow  folds  yields  a  drop  of  lymph 
streaked  with  blood. 

Treatment,  which  should  be  practiced  only  when  the  lymph- 
angioma increases  in  size,  or  when  it  is  already  of  excessive  dimen- 
sions, is  the  same  as  for  angioma.  It  is  possible  that  the  X-rays 
may  in  the  future  afford  a  painless  and  more  rapid  result,  but  this 
is  not  yet  confirmed. 

MARGINATE    EXFOLIATING   GLOSSITIS. 

This  occurs  most  often  in  childhood,  but  also  in  the  adult  during 
the  first  half  of  life,  becoming  more  and  more  rare  with  age.  It 
is  a  chronic  disease,  lasting  for  months  and  years  and  recurring 
after  periods  of  apparent  cure.  It  presents  no  functional  symptoms, 
so  that  the  patient  only  becomes  aware  of  it  by  chance.  The  dorsal 
surface  of  the  tongue  is  covered  with  segments  of  grey  circles, 
mingled  without  any  arrangement.  These  are  of  various  sizes,  but 
more  often  belong  to  circles  with  a  diameter  of  5  to  10  millimetres. 
When  several  circles  intersect  the  parts  intersected  disappear,  leav- 
ing an  ornamental  polycyclic  design.     These  figures  are  caused  by 


46  THE    TONGUE. 

an  adherent  epithelial  accumulation  analogous  to  a  squame  on  the 
skin.  A  curious  fact  is  that  the  designs  change  in  form  and  position 
from  day  to  day.  One  day  there  is  a  patch  and  the  next  day  a  ring. 
These  lesions,  like  many  cutaneous  lesions,  commence  by  a  disc  of 
hyperkeratosis  the  diameter  of  which  increases;  then  the  mucosa 
becomes  normal  in  the  centre  and  the  disc  becomes  a  circle. 

The  cause  and  nature  of  the  lesion  are  unknown :  Parrot  regarded 
it  as  syphilitic  and  Foiirnier  as  parasyphilitic,  but  it  does  not  appear 
to  me  to  have  anything  in  common  with  syphilis,  acquired  or  heredi- 
tary. It  has  also  been  considered  to  be  eczematous,  psoriasic,  etc., 
but  it  is  observed  in  the  absence  of  both  these.  The  only  thing 
certain  is  that  the  disease  is  absolutely  benign. 

Xo  treatment  appears  to  have  any  effect  and  anything  may  be 
prescribed  except  irritating  medicaments :  Vichy  water,  St. 
Christau  water,  gargles  and  mouth  washes,  balsam  of  Peru,  etc.  It 
is  well  to  remember  the  long  duration  of  the  affection  and  its  recur- 
rences. 

APHTHAE. 

I  have  described  aphthae  in  speaking  of  the  affections  of  the  mouth 
in  general  (p.  38)  ;  they  are  situated  on  the  borders  or  tip  of  the 
tongue.    They  present  nothing  particular  in  this  region. 

THRUSH. 

I  have  already  described  the  thrush  (p.  38)  ;  that  of  the  tongue 
presents  no  peculiarity  worthy  of  attention. 

SIMPLE   LEUCOPLASIA. 

Leucoplasia  has  also  been  described  with  the  diseases  which  are 
observed  in  all  parts  of  the  mouth  (p.  39).  Simple  leucoplasia  of 
the  tongue  is  only  an  epiphenomenon  of  buccal  leucoplasia:  one 
hardly  exists  without  the  other.  This  character  generally  differs 
from  that  of  syphilitic  leucoplasia,  which  has,  like  tertiary  syphilis  in 
general,  a  special  predilection  for  the  tongue. 

Leucoplasia  of  the  tongue  has  the  same  characters,  prognosis  and 
treatment  which  we  have  described  in  all  its  situations. 


THE    TONGUE.  47 

SYPHILITIC    CHANCRE. 

Syphilitic  chancre  of  the  tongue  is  always  situated  at  the  tip  or  on 
the  border  of  the  anterior  part.  It  is  of  moderate  dimensions  and 
usually  characterised  by  its  round  or  oval  form  and  its  exulcerated 
surface,  the  absence  of  ulceration  and  discharge,  the  saucer-like 
depression,  cartilaginous  hardness,  sub-hyoid  satellite  gland  (p.  252) 
and  indolence ;  its  evolution  in  4  or  5  weeks  and  its  spontaneous 
resolution  and  cure. 

No  local  treatment  is  required.  The  treatment  is  antisyphilitic. 
Extra-genital  chancres  have  not  a  particularly  grave  prognosis. 
(  A.  Fournier). 

MUCOUS    PATCHES. 

Mucous  patches  of  the  tongue  present  three  forms  which  can 
be  clearly  distinguished  from  one  another:  the  normal  exulceration, 
the  hypertrophic  pseudo  papillomatous  and  the  smooth  depapillated 
patch. 

1.  The  typical  Mucous  patch  is  a  flat  exulceration  slightly 
depressed,  with  a  grey  base,  non-suppurative,  with  a  red  margin 
sometimes  surrounded  by  a  grey  ring  rendering  its  dimensions 
larger.  The  Mucous  patch  of  this  type  occurs  on  the  tongue,  or 
underneath  it,  and  also  inside  the  cheeks,  lips  and  mouth.  Mucous 
patches  of  the  tongue  co-exist  nearly  always  with  a  series  of  similar 
patches  on  the  pillars  of  the  fauces  and  the  free  border  of  the  soft 
palate  (p.  68). 

The  two  other  types  of  secondary  patches  are  not  true  mucous 
patches,  but  lesions  of  the  back  of  the  tongue  homologous  to  the 
secondary  papules  of  the  skin. 

2.  Hypertrophic  pseudo-papillomatous  patches.  These  are 
placed,  one,  two  or  three  in  number,  on  the  back  of  the  tongue,  near 
the  lingual  V.  They  form  hard  regular  eminences  (bosses)  cov- 
ered with  hypertrophied  villous  papillje. 

3.  Depapillated  patches  occur  fairly  often  on  the  tongue,  appear- 
ing like  "heavy  steps  on  fine  turf".  In  several  oval  areas  the  papilLx 
appear  to  be  absent  and  to  have  been  shaved  with  a  razor,  or  flat- 
tened so  as  to  be  invisible;  while  around  these  patches  the  papillae 
have  preserved  their  normal  number  and  disposition. 

These  different  lesions  are  simple  epiphenomena  of  a  general 


^  THE    TONGUE. 

disease  of  wkich  the  general  treatment  only  is  important.  It  is  the 
custom  to  cauterise  the  true  mucous  patches  with  nitrate  of  silver 
but  not  the  hyperthropic  or  depapillated  ones!  A  true  therapeutic 
idea  or  a  prejudiced  one? 

TERTIARY    SYPHILIS    OF   THE    TONGUE. 

The  tongue  may  present  the  syphilitic  gu))iiiia  of  the  normal  type, 
the  size  of  a  nut,  hard  and  painless ;  later  on  ulcerated,  and  eliminat- 
ing a  yellow  sphacelus  from  a  deep  crater.  An  important  negative 
symptom  is  the  absence  of  adenopathy.  Tertiary  syphilis  of  the 
tongue  usually  occurs  in  the  form  of  Sclerous  Glossitis,  which  is 
one  of  the  most  common  and  special  manifestations  of  the  disease. 
The  tongue  is  much  increased  in  size  and  deformed  by  irregular 
swellings.  It  is  also  divided  by  deep  longitudinal  folds — often 
exulcerated  and  bordered  with  rhagades.  Finally,  the  tongue  may 
be  covered  with  white  irregular  cicatrices,  often  adjoining  ulcer- 
ations in  process  of  cicatrisation,  the  scars  of  which  are  added  to 
the  existing  cicatrices. 

The  irregular  bosses  covering  the  tongue  are  gummata.  They 
are  hard,  often  elongated  in  the  direction  of  the  tongue,  or  some- 
times separated  from  each  other  by  cicatrices.  They  do  not  soften 
and  ulcerate  like  ordinary  gummata,  but  always  retain  their  hard- 
ness. 

The  folds  are  due  to  increase  in  the  volume  of  the  tongue  and  are 
formed  as  in  congenital  macroglossia,  in  proportion  as  the  total 
volume  of  the  tongue  increases.  They  are  often  bordered  with 
exulcerations,  or  the  bottom  of  the  fold  may  be  fissured.  The  exul- 
cerations,  which  are  rarely  deep  but  tenacious,  precede  and  cause 
the  cicatrices.  These  cicatrices  form  grey  bands  which  bridle  the 
tongue  and  form  a  sort  of  lobulation  on  the  surface.  An  ulcera- 
tion is  often  continued  by  a  cicatrix  and  z'ice  versa.  The  appearance 
of  these  lesions  is  characteristic  and  nothing  can  simulate  it.  They 
are  extremely  chronic  and  are  improved  but  not  cured  by  ordinary 
remedies.  They  may  last  for  6  to  lo  years  and  more.  It  is  prob- 
able, but  not  certain,  that  they  are  not  contagious.  They  are  more 
common  in  males  than  in  females  and  are  often  tenacious  in  smokers. 

Both  external  and  internal  treatment  are  required.  Externally 
mouth  washes  with  alkaline  water  or  St,  Christau  water,  etc.,  are 
useful,  but  especially  repeated  painting  of  the  fissures,  rhagades  and 


THE    TONGUE.  49 

ulcerations  with  chromic  acid  (co  per  cent.).    The  lesions  may  also 

be  touched  with  chromic  acid  crystals.     Relief  is  almost  immediate. 

Internal  treatment  should  be  active ;  pills  and  inunction  must 

be  disregarded  and  injections  of  calomel  or  biniodide  employed. 

I.  Calomel      4  centigrammes  (gr.  4/7) 

Oil  of  almonds  fresh   .    .    .1  cubic  centimeter  (M  17) 
Sterilize   and   stir   thoroughly   before   use. 
Inject  every  week  in  alternate  buttocks. 

2.  Biniodide  of  mercury   ...    2  centigrammes  (gr.  2/7) 

Distilled  water i  cubic  centimeter  (M  17) 

Iodide  of  sodium Qs  to  dissolve. 

Inject  daily. 

3.  Gray  oil i  in  40 

Inject  8  centigrammes  (gr.  i   1/7)  twice  a  week. 

This  treatment  must  be  continued,  under  supervision,  for  a 
long  time  and  only  interrupted  in  case  of  supersaturation  (stoma- 
titis, etc.).  But  the  patient  should  be  informed  that  this  is  one  of 
the  most  tenacious  localisations  of  the  disease  and  one  of  those 
which  should  be  attacked  with  the  most  intense  treatment. 
Gumma  of  the  tongue  on  the  other  hand  yields  readily  to  anti- 
syphilitic  treatment. 

SYPHILITIC    LEUCOPLASIA. 

This  often  accompanies  the  preceding  lesions  and  develops  in 
a  tongue  previously  prepared  by  Sclerosing  Glossitis.  In  this 
case  the  diagnosis  is  certain ;  in  others  leucoplasia  takes  a  dif- 
ferent course  and  closely  resemble  non-syphilitic  leucoplasia 
described  on  page  39. 

Except  in  doubtful  cases,  syphilitic  leucoplasia  is  characterised 
by  its  exclusive  localisation  on  the  tongue,  without  leucoplasic 
lesions  of  the  gums,  cheeks  and  lips.  As  a  rule  the  hyperkera- 
totic  patch  is  diffuse,  with  borders  which  are  recognisable,  but 
not  limited  so  strictly  as  in  essential  leucoplasia.  Syphilitic  leu- 
coplasia usually  develops  on  a  subjacent  sclerosis  which  is  per- 
ceptible to  the  touch,  and  is  usually  accompanied  by  lesions  of 
sclerosing  glossitis.  The  duration  of  the  lesion  is  unlimited,  and 
when  once  formed  it  is  permanent.  Epithelioma,  without  being 
the  rule,  sometimes  complicates  it.     The  action  of  local  treat- 


50  THE    TONGUE. 

ment  is  almost  nil:  the  general  treatment  is   the   same  as  for 
sclerosing  glossitis,  which  we  have  just  considered  (p.  49). 

DENTAL    GLOSSITIS. 

Dental  glossitis  occurs  when  the  tongue  is  subject  to  chronic 
Irritation  by  teeth  which  are  misplaced,  inwardly  projecting  or 
with  broken  edges ;  especially  when  the  care  of  the  mouth  is  neg- 
lected, when  the  denuded  teeth  are  covered  with  tartar  and  the 
gums  suppurating,  and  especially  when  the  profession  of  the 
patient  requires  much  speaking.  The  swollen  and  painful  tongue 
bears  the  inprints  of  the  existing  teeth  and  projections  where  the 
teeth  are  absent. 

Simple  dental  glossitis  is  not  severe  and  disappears  when  the 
cause  is  removed.  Irreparable  teeth  should  be  extracted,  tartar 
removed  and  antiseptic  lotions,  such  as  the  following,  applied 
daily  to  the  gums  : — 

Alcohol    (60  per  cent.) |      20  parts 

Tincture    of    cochlearia j 

Tincture    of   iodine 10 


TRAUMATIC    ULCERATIONS. 

These  are  more  severe  cases,  consisting  of  chronic  ulcers  with 
callous  and  sometimes  vegetating  borders,  produced  by  the  irri- 
tations of  a  broken  tooth.  The  lesions  are  always  situated  on 
the  borders  of  the  tongue,  and  the  tooth  which  gives  rise  to  them 
can  always  be  discovered. 

The  offending  tooth  must  be  removed  and  mouth  washes  of  St. 
Christau  water  and  emollient  applications  used,  such  as  marsh- 
mallow.  In  three  weeks  the  lesion  is  usually  transformed,  leav- 
ing a  thin  white  cicatrix  the  induration  of  which  disappears 
gradually. 

It  must,  however,  b»  borne  in  mind  that  a  traumatic  lesion  of 
this  kind  may  be  the  origin  of  an  epithelioma,  and  if  the  ulcera- 
tion persists  or  increases  after  avulsion  of  the  tooth  a  ■biopsy- 
should  be  made  which  will  indicate  intervention. 


THE    TONGUE. 


St 


LINGUAL    TUBERCULOSIS. 

I  have  only  seen  this  inthe  subjects  of  pronounced  tuberculosis 
or  when  the  apices  of  the  lungs  were  suspected;  generally  in  the 
emaciated  subjects  of  phthisis. 

The  tuberculous  ulcer  may  occur  on  the  soft  palabe  (p.  70), 
or  on  the  toijgue  (Fig.  22),  or  on  the  inner  surface  of  the  lips, 

with  the  same  characters.  It  is  a 
deep  ulceration  with  sharp  cut 
ragged  borders,  like  the  crevasse 
of  a  glacier.  On  separating  these 
borders  there  is  found  at  the 
depth  of  a  few  millimetres,  an 
ulcerated  yellow  base  stippled 
with  orange  red,  bleeding  easily 
and  painful. 

One  or  both  borders  of  the 
ulcer  are  callous,  hyperkeratotic 
and  covered  with  red  points  cir- 
cled with  yellow.  Sometimes  a 
small  ulcer  exists  by  the  side  of 
the  large  one. 

The  border  of  the  tuberculous  ulcer  is  sometimes  a  hard,  raised, 
gummatous  mass :  or  its  base  may  rest  on  a  gummatous  sheet. 
Microscopic  diagnosis  is  nearly  always  easy.  It  is  sufficient  to 
examine  a  trace  of  the  necrosed  tissue  from  the  bottom  of  the 
ulcer  by  ordinary  methods.  The  bacillus  of  Koch  swarms  there. 
The  evolution  of  this  ulcer  is  chronic  and  progressive.  Some- 
times external  treatment  may  cure  it,  but  the  patients  die  of  their 
pulmonary  tuberculosis  like  those  afTected  with  tuberculous 
pharyngitis  or  laryngitis.  They  are  nearly  always  the  subjects 
of  incurable  tuberculosis.  Local  treatment  consists  in  the  daily 
applications  of  pvire  lactic  acid  or  concentrated  solutions,  or  chlor- 
ide of  zinc  ( I  in  15  to  I  in  20),  etc.  This  affection  is  too  uncom- 
mon to  enable  us  to  speak  yet  of  the  results  of  radiotherapy. 

EPITHELIOMA. 


I'ig.  32.    Lingual    Tuberculosis.     (Bes 

nier's    patient.     St.    Louis    Hosp. 

Museum,    Ko.    344.) 


The  treatment  of  lingual   epithelioma  hardly  comes   within  the 
province  of  dermatology,  but  it  is  usually  the  dermatologist  wha 


52  THE    TONGUE. 

is  first  consulted,  so  long  as  the  patient  in  these  cases  fears  the 
surgeon.  Epithelioma  of  the  tongue  is  usually  hypertrophic; 
rarely  ulcerative. 

It  may  be  primary  or  secondary  to  essential  leucoplasia,  syphil- 
itic sclerosing  glossitis  or  chronic  dental  ulcer,  etc.  It  occurs  at 
the  usual  age  of  cancer,  about  50  years,  often  in  younger  people, 
and  is  more  common  in  males. 

It  generally  forms  a  mammillated  tumour,  very  irregular,  larger 
at  the  base  than  at  the  apex,  of  irregular  conformation,  and  cov- 
ered by  the  normal  mucosa  of  the  tongue,  the  villous  structure  of 
which  is  exaggerated  and  covered  by  an  adherent  hyperkeratotic 
coating.  Sometimes  the  hyperplastic  development  of  the  tumour 
is  more  marked  and  it  is  lobulated  and  riddled  with  clefts  separat- 
ing the  digitations.  At  other  times  it  forms  a  vegetating  ring  on 
a  flat  base,  in  the  form  of  a  sea-anemone :  sometimes  a  tumour 
developing  in  the  substance  of  the  muscle  like  a  nut  enclosed  in 
the  tongue.  Later  on  this  tumour  becomes  ulcerated,  the  ulcera- 
tion being  situated  on  an  ill-defined  deep  infiltration.  The  everted 
borders  form  rounded  swellings,  and  the  sanious  base  discharges 
an  oflfensive  liquid.  Haemorrhages  are  common,  and  sometimes 
severe.  The  subjective  signs  are  very  marked:  pain,  dysphagia 
salivation  and  otalgia.  The  sub-maxillary  or  sub-hyoid  glands 
enlarge  and  the  termination  is  that  of  all  cancers. 

The  differential  diagnosis  from  tertiary  gummatous  syphilis 
and  hypertrophic  tuberculosis  may.  in  certain  cases,  be  impos- 
sible, and  a  biopsy  may  be  necessary.  A  small  fragment  taken 
with  a  Gracfe's  knife  or  with  scissors  is  sufficient.  Cicatrisation 
is  effected  in  a  few  days. 

Diagnosis  is  necessary  on  account  of  intervention,  for  a  trial  of 
anti-syphilitic  treatment  is  more  harmful  to  a  cancer  of  the  tongue 
than  the  biopsy  of  a  fragment  as  large  as  a  nail  paring,  which  is 
in  itself  insignificant.  Treatment  of  cancer  of  the  tongue  at  the 
present  time  appears  to  consist  in  complete  excision,  followed  by 
radiotherapy  of  the  cicatrix.  At  the  commencement  of  an  epithe- 
liomatous  lesion  radiotherapy  may  be  tried  without  excision, 
because  the  X-rays  are  borne  by  the  mucous  membrane  in  very 
high  doses.  Sittings  of  6  or  7  units  of  Holznccht  may  be  given 
to  the  tongue  without  the  least  radiodermatitis.  Several  sittings 
are  necessary.  The  tumour  undergoes  resolution,  and  is  reduced 
to  a  fibrous  stump  which  I  have  never  seen  disappear  altogether. 


THE    TONGUE.  $3 

1  have  observed  such  a  case  for  six  months/  Radiotherapy 
should  also  be  regarded  as  a  useful  and  moral  method  in  all  cases 
of  inoperable  epithelioma. 

Radiotherapy  of  the  glands  should  never  be  neglected,  as  this 
gives  surprising  results  and  seems  to  diminish  the  further  prop- 
agation of  the  disease. 

VARIA. 

Bullous  Hydroa  is  an  indefinite  dermatosis  which  may  have 
been  artificially  constructed  with  cases  of  streptoccocic  impetigo 
of  mucous  membranes,  which  are  not  well  known  and  certainly 
rare ;  with  cases  of  polymorphous  erythema  with  accessory  buccal 
localisation;  or  more  often  with  cases  of  dermatitis  herpetiformis 
of  Duhring-Brocq  (p.  ).  The  eruption  is  characterised  by  the 
appearance  in  the  mouth  of  a  multitude  of  phlyctenular  lesions 
which  rupture,  leaving  transient  exulcerations.  The  functional 
symptoms  are  those  of  severe  stomatitis.  The  duration  of  the 
attack  is  short,  from  lo  to  15  days,  but  there  is  always  recurrence. 
The  treatment  is  purely  symptomatic  and  palliative. 

Lichen  planus  of  the  tongue  is  less  common  than  on  the  inner 
surface  of  the  cheek  (p.  y2>)-  It  consists  of  one  or  more  grey 
])atches,  very  much  resembling  leucoplasia,  but  quadrilateral,  with 
greyish  blue  arborescences,  which  traverse  the  grey  patch  like  fine 
linear  cicatrices.  These  lesions  require  no  treatment  beyond  that 
for  the  disease  which  causes  them  (lichen  planus  of  Erasuius 
Wilson  (p.  553)- 

Black  Tongue  is  the  name  given  to  a  lingual  mycosis  common 
among  old  people  and  in  asylums.  It  is  a  mycosis  of  old  people 
corresponding  to  thrush  of  the  young. 

It  is  seldom  accompanied  by  functional  symptoms ;  only  slight 
dysphagia  and  dryness  of  the  tongue.  The  tongue  is  generally 
covered  with  two  symmetrical  black  patches,  elongated  in  its 
major  axis,  separated  by  the  median  raphe  and  larger  towards  the 
lingual  V.  On  these  surfaces  the  villous  structure  of  the  tongue 
is  exaggerated  and  hyperkeratotic  papilae  project,  or  lie  flat  on 
the  tongue  in  all  directions  like  long  grass  in  a  meadow. 

^According  to  some  authors  the  lobiilated  pavement  epitheliomas 
which  are  common  on  the  tongue  and  lower  lip  give  no  result  with 
radiotherapy. 


54  THE    TONGUE. 

The  disease  appears  due  to  a  mycotic  parasite,  of  undeter- 
mined species,  easily  cultivated  in  glycerine  gelose. 

Treatment  consists  of  the  application  of  an  alcoholic  solution 
of  salicylic  acid  (lo  per  cent.)  ;  camphorated  ether  or  oxygenated 
water. 

Glcsscdjmia.  Some  people  are  affected  by  constant  pains  in 
the  tongue  increased  by  speech,  mastication,  tobacco,  spices,  etc. 
Nothing  is  seen  on  examination,  but  the  patient  points  out  such 
and  such  a  papilla  as  the  seat  of  pain  at  the  moment.  At  other 
times  it  is  a  papilla  of  the  lingual  V  which  is  said  to  be  painful. 

Patients  who  have  these  pains  are  without  exception  neurotic, 
generally  suggestive  neurotics.  They  spend  their  time  in  examin- 
ing their  papillae,  which  they  regard  as  lesions  of  the  mucous 
membrane.  These  glossodynias,  true,  or  suggested  by  the 
patient  herself,  constitute  a  more  or  less  marked  nervous  state. 
The  patients  should  be  treated  as  neurasthenics,  but  it  is  always 
useful  to  prescribe  local  applications  and  to  appear  to  attach 
importance  to  them.  By  this  means  the  patient  may  be  relieved 
for  several  weeks,  but  the  remedy  should  be  varied  according  to 
the  inevitable  relapses  in  such  conditions. 

Ulceration  of  a  fraenum  of  the  tongue.  Ulceration  of  the 
fraenum  of  the  tongue  may  accompany  spasmodic  and  convulsive 
cough,  especially  whooping  cough  in  children.  This  ulceration 
is  produced  by  the  fraenum  striking  the  lower  incisor  teeth  at  the 
moment  when  the  tongue  is  projected  from  the  mouth.  It  occurs 
as  a  small  linear  transverse  ulceration,  which  becomes  greyish  on 
the  following  day.  It  only  requires  mention  owing  to  the 
confusion  to  which  it  may  give  rise. 


THE   GUMS. 

The  gums,  among  all  the  buccal  regions,  have  a  morbid  and  pecu- 
liar dermatological  autonomy. 
We  shall  study  successively: — 

Simple  gingivitis  due  to  want  of  hygiene  and  the^ 
accumulation  of  dental  tartar,  or  to  the  eruption  of  r  Simple       Gingivitis  p.  55 
the  zvisdom  teeth -' 

TJiis  may  under  certain  conditions  of  bad  health,']  

,  J-  7    ,  J      >•  ;       •         7  I  Diabetic    gingivitis, 

such    as    diabetes    and    divers    cachexias,    become  r  00. 

,        ^    ,  I      etc p.  56 

ulcerated -'  ^  -^ 

Gingivitis   or  stomatitis  due   to   acute   mercurial}  ^,  

^    ■       ■        ■          ,,  u  '  JMercunal  gingivitis  p.  57 

poisoning  IS  zuell  knozi'n j  ^ 

A    gonorrhoeal    gingivitis    has    been    described,'] 
zdiich  is  at  least  rare  and  of  zvhich  zee  shall  on/jl  ^°"°"''"^^'        ^'"' 
say  a  fezv  zuords J      ^^^'^'^ P- 58 

Alveolo-dental  pyorrhoea  belongs  to  the  domain^ 
of  stomatologists  rather  than  to  that  of  dcrmatolo-Y^^'^^^^^'^^"^^^   P>'" 
gists.     But  the  symptoms  should  at  least  be  knoz^ni^      orhoea p.  58 

The  gums  form  one  of  the  localisations  of  lead') 
in  saturnism )  Saturnism     ....  p.  59 

We  shall  briefly  survey  the  tumours  zn'hich  or /'g-l  Epulis       Malignant 

inate  from  the  gums  and  maxilla J      Tumours       .    .    .   p.  60 

Lupus  of  the  gums  has  been  described  above  .    .    Lupus P-  41 


Many  lesions,  such  as  ulcero-membranous  gingivitis,  aphthae, 
mucous  patches  and  leucoplasia  occur  on  the  gums,  as  on  all  parts 
of  the  mouth,  and  have  been  studied  with  the  dermatological  lesions 
of  the  mouth  in  general. 

SIMPLE    GINGIVITIS. 

In  persons  having  chemical  disorders  of  the  saliva,  and  in  those 
who  neglect  the  care  of  the  mouth,  an  accumulation  of  dental  tartar 
takes  place  on  the  teeth  beyond  the  point  of  emergence  from  the 
gums.  This  forms  a  chalky  concretion,  very  adherent  of  the  teeth, 
but  removable  by  any  instrument.  Sometimes  the  tartar  pushes  back 
the  gum  and  lays  bare  the  tooth,  generally  the  incisors,  for  a  third 
or  half  of  the  root. 


56  .  THE    GUMS. 

The  resultino-  gingivitis  covers  the  alveolar  border  with  grey  or 
greenish  epithelical  debris  under  which  the  mucous  membrane  is 
apparently  intact,  but  bleeds  easily.  This  condition  is  common,  and 
the  somewhat  putrid  breath  of  the  subject  should  draw  attention  to 
the  affected  region.     The  treatment  is  simple. 

1.  The  tartar  should  be  removed  by  a  dentist. 

2.  Prescribe  the  following  dentifrice : — 


Chlorate  of  potash i  part 

Prepared  chalk 

Soap 


I  aa.  ID  parts 


3.     Applv  with  a  brush  every  other  day,  to  the  gums  and  to  the 
sides  of  the  teeth,  a  layer  of  this  liniment : — 

Tincture   of   iodine    

Tincture  of  cochlearia   

Spirit    of    lavender }-  equal  parts 

Tincture    of    aconite 

Alcohol    (60  per  cent.) 


GINGIVITIS    OF    THE    WISDOM    TEETH. 

The  eruption  of  the  last  teeth  is  always  the  occasion  for  local  con- 
gestive phenomena  and  lacerations  of  the  gum,  which  may  in  their 
turn  be  the  point  of  origin  of  superficial  or  deep  suppurative  gin- 
givitis. 

Whatever  type  gingivitis  assumes,  this  cause  must  always  be  looked 
for,  as  it  may  easily  escape  detection.  Having  discovered  the  cause, 
the  gum  is  treated  by  lancing,  or  excision  of  the  proud  flesh  round 
the  teeth,  or  by  cauterisation  with  the  galvano-cautery.  This  cause 
being  removed,  the  gingivitis  should  be  easy  to  reduce.  According 
to  its  gravity  the  case  should  be  treated  by  the  methods  indicated  in 
the  preceding  or  following  chapters. 


ULCERATIVE     GINGIVITIS.      SCORBUTUS       NOSTRAS.     DIA- 
BETIC   GINGIVITIS. 

Under  the  influence  of  the  different  causes  mentioned  above,  and 
divers    intoxications,    such    as   phosporous   and   lead,    or   in    many 


THE    GUMS.  57 

cachectic  conditions,  an  ulcerative  gingivitis  may  be  established 
affecting  not  only  the  epidermis  but  the  dermis. 

The  breath  is  extremely  foetid  and  the  gums  on  examination  are 
found  to  be  swollen,  thickened  and  ulcerated  over  their  whole 
alveolar  extent,  on  both  sides  of  the  teeth,  but  especially  externally. 
The  teeth  may  be  more  or  less  denuded  according  to  the  depth  of  the 
ulceration,  and  are  sometimes  loose.  The  ulceration  follows  the 
alveolar  border  and  is  covered  with  pus  and  grey  or  greenish 
necrotic  detritus.  The  base  of  the  ulceration  is  not  flat,  but  irregu- 
lar, and  studded  with  small  fleshy  granulations.  According  to  symp- 
tomatic details,  such  as  more  or  less  free  haemorrhage,  the  stomatitis 
has  taken  different  names,  such  as  Scorbutus  nostras;  or  may  be 
named  after  its  chief  cause.  Diabetic  gingiz'itis.  It  appears  to  be 
always  the  same  non-specific  affection  determined  by  the  pyogenic 
microbes  of  ordinary  suppuration. 

In  nearly  every  case,  the  influence  of  the  general  condition 
explains  the  gravity  of  the  process.  It  is  an  affection  of  cachexia, 
which  may  be  transient,  or  profound  and  chronic  (diabetic,  can- 
cerous, tuberculous,  etc.).  In  nearly  all  cases  it  is  thus  necessary 
to  examine  the  patient  completely  and  to  investigate  his  general  con- 
dition in  order  to  indicate  the  appropriate  treatment.  After  this, 
local  treatment  consists  in  the  application  of  chlorine  water,  or 
oxygenated  water.  When  healthy  granulations  appear  the  cure  is 
completed  by  weak  applications  of  iodine  of  the  kind  indicated  on 
page  56. 

MERCURIAL   GINGIVITIS. 

Gingivitis  is  invariably  the  point  of  origin  of  mercurial  stomatitis, 
and  the  gingii^al  irritation  begins  around  the  root  of  a  semi-decayed 
tooth  or  a  wisdom  tooth  in  process  of  eruption.  It  always  com- 
mences on  one  side  by  a  painful  swelling  of  the  gum  and  a  peridental 
necrotic  patch.  At  the  same  time  there  is  ptyalism  and  a  flow  of 
saliva,  which  in  severe  cases  may  run  from  the  mouth  continuously 
for  several  days.  In  those  cases  the  swelling  of  the  gum  becomes 
generalised  and  the  necrotic  patches  multiply,  giving  to  mercurial 
stomatitis  a  strong  resemblance  to  ulcero-membranous  stomatitis. 
The  grey  or  yellow  patches  of  necrosis  may  be  seen  also  on  the  bor- 
der of  the  tongue  and  on  the  inner  surface  of  the  cheeks.  They 
exhale  a  foetid  odour.     In  benign  cases  mercurial  gingivitis,  which 


58  THE  GUMS. 

is  only  characterised  by  painful  swelling  of  the  gums  and  salivation, 
lasts  three  or  four  days. 

In  severe  cases,  accompanied  by  patches  of  ulcerative  gingivitis, 
it  may  last  from  lo  to  15  days  or  more.  Formerly  one  used  to  see 
gingivitis  followed  by  loss  of  the  teeth  and  even  necrosis  of  the 
jaw,  as  in  phosphorous  poisoning  among  matchmakers.  The  sensi- 
bility of  different  persons  to  mercury  varies  considerably :  some  sub- 
jects have  ptyalism  after  a  few  pills  of  proto-iodide,  but  it  is  mer- 
curial inunction  or  injection  which  most  commonly  causes  gingivitis. 
Formerly  it  was  encouraged,  on  the  supposition  that  the  syphilitic 
virus  was  eliminated  by  the  saliva.  Hence  the  severe  accidents 
which  formerly  occurred  during  mercurial  treatment,  and  the  opin- 
ion which  certain  people  still  hold  concerning  it. 

Directly  mercurial  gingivitis  commences,  the  ingestion,  inunction 
or  injection  of  mercury  must  be  stopped,  and  the  skin  of  the  patient 
cleansed  after  inunction.  The  elimination  of  mercury  must  be 
assisted  by  laxatives  and  diuretics.  Finally,  the  gingivitis  is  treated 
in  the  same  way  as  all  ulcerative  gingivitis  (p.  57),  for,  if  the 
elimination  of  mercury  by  the  saliva  is  the  primary  cause,  its 
development  is  due  to  local  microbial  infection. 

GONORRHOEAL   GINGIVITIS. 

I  have  only  seen  a  single  case,  and  possibly  this  was  an  ulcerative 
gingivitis  with  secondary  infection  by  the  gonococcus,  arising  from 
a  concomitant  acute  gonorrhoea.  The  appearance  was  that  of  ulcer- 
ative gingivitis  with  irregular  deep  lesions,  very  necrotic  and  very 
foetid.  The  pus  was  streaked  with  blood  and  the  least  touch  caused 
bleeding.  The  lesions  were  cured  in  12  to  15  days  by  the  applica- 
tion of  lactic  acid  (10  per  cent.). 

ALVEOLO-DENTAL    PYORRHOEA. 

This  name  is  given  to  a  chronic  suppurative  arthritis  which  usu- 
ally extends  to  all  the  teeth  of  one  or  both  jaws.  Probably  it  is  a 
suppuration  of  a  common  kind,  like  that  of  sycosis,  but  still  more 
intractable.  When  the  tooth  of  the  suppurating  alveolus  is  pressed 
upon,  it  becomes  surrounded  at  its  point  of  emergence  from  the 
alveolus  by  a  thin  border  of  pus.     The  peri-dental  ligament  and 


THE  GUMS.  .  59 

the  inter-alveolo-dental  space  are  not  easily  infected,  for  many  cases 
of  gingivitis  develop  without  causing  pyorrhoea,  in  the  same  way 
as  many  suppurations  of  the  skin  do  not  affect  the  hairy  follicles 
of  the  region.  But  infection  of  this  space  when  once  established  is 
usually  chronic,  like  that  of  the  follicles  in  sycosis.  This  compari- 
son may  be  extended,  for  all  the  teeth  become  affected  one  by  one, 
as  all  the  follicles  attacked  in  sycosis  of  a  hairy  region. 

This  chronic  suppuration  causes  loosening  of  all  the  affected  teeth, 
followed  by  their  expulsion,  after  the  manner  of  a  foreign  body. 
Finally  the  alveolar  cavity  becomes  effaced  by  progressive  sclerosis, 
forming  a  cicatrix,  in  the  same  way  that  the  infective  follicles  in 
sycosis  undergo  spontaneous  cure  by  expulsion  of  the  hair  and  the 
formation  of  a  cicatrix. 

Alveolo-dental  pyorrhcea  is  not  very  painful  but  constitutes  a  dis- 
tressing infirmity  by  its  chronfcity,  ending  with  the  loss  of  each  tooth, 
whether  healthy  or  carious,  but  more  often  healthy. 

It  has  been  proposed  to  place  this  affection,  like  all  chronic 
cutaneous  lesions,  under  the  head  of  arthritism,  but  considering  the 
uncertainty  of  the  definition  of  this  word  we  might  make  it  the 
cause  of  any  disease  we  wished.  If  a  general  condition  causes 
alveolo-dental  pyorrhoea,  it  is  one  which  can  be  neither  defined  nor 
treated.  The  local  treatment  of  this  disease  belongs  to  stomatolog}-. 
It  is  difficult  for  the  same  reasons  that  sycosis  is  for  dermatologists. 
Avulsion  of  the  tooth  causes  disappearance  of  suppuration,  as  epila- 
tion of  the  hair  in  sycosis  suppresses  folliculitis;  but  the  tooth  like 
the  hair  does  not  grow  again. 

Peri-dental  injections  of  chloride  of  zinc  (i  to  15)  by  means  of 
a  Pravas  needle  give  temporary  results.  The  treatment  is  tedious 
and  requires  frequent  repetition,  but  may  lead  to  survival  of  the 
teeth  for  some  years. 

SATURNISM. 


There  is,  properly  speaking,  no  Saturnine  gingivitis,  since  chronic 
lead  poisoning  does  not  cause  suppuration  of  the  gums  and  leaves 
the  mucosa  intact.  One  observes  only  in  the  saturnine  a  greyish 
blue  border  traced  under  the  epidermis  of  the  gums  and  extending 
along  all  the  teeth.  This  is  a  deposit  of  sulphide  of  lead  shewing 
through  the  mucous  membrane. 


«o  THE  GUMS. 

When  this  lesion  is  met  with  the  patient  should  be  warned  of  the 
imminence  of  severe  disorders — paralysis  and  lead  colic,  and  pre- 
ventive treatment  should  be  instituted  by  laxatives  of  sulphur,  sul- 
phuric lemonade  and  sulphur  baths. 

It  is  probable  that  lead  may  determine  an  acute  gingivitis  like  mer- 
cury, but  the  intoxication  is  rarely  so  rapid  as  to  produce  this  phe- 
nomenon. 

EPULIS.     GINGIVAL    TUMOURS. 

The  mucosa  of  the  gums  may  become  the  seat  of  development  of 
divers  malignant  tumours.  The  old  epulis  was  more  often  a  sar- 
coma arising  in  the  inter-dental  space  and  assuming  the  form  of  a 
malignant  tumour. 


lary        conforma- 

tion      

p.  6r 

Defects     of     dental 

implantation     .    . 

p.  62 

Defects   of   number 

P-63 

Defects    of    dimen- 

sions   

P-63 

THE   TEETH. 

Diseases  of  the  teeth  are  beyond  the  scope  of  this  vokime  and 
I  shall  only  deal  with  certain  disorders  of  osseous  and  dental  evolu- 
tion which  serve  as  a  retrospective  diagnosis  for  hereditary  syphilis. 
Under  this  heading  the  following  affections  merit  attention. 


/  shall  first  speak  of  certain  defects  of  formation  j  Defects    of    maxil- 
of  the  maxillae  and   of   the  special  aspect  zvhich 
results  therefrom ^ 

/  shall  then  mention  changes  peculiar  to  the" 
teeth  and  shall  survey  successively  the  defects  of 
implantation,  number,  form  and  dimensions  of  the 
teeth,  the  latter  being  more  frequent  and  more 
important J  Defects    of    form  .  p.  64 

Before  dealing  with  any  of  these  lesions  it  is  necessary  to  explain 
their  nature  and  value.  None  of  them  are  exclusively  characteris- 
tic of  hereditary  syphilis  and  none  are  syphilitic  in  themselves.  In 
syphilitic  parents  the  intoxication  caused  by  the  infection  is  so  pro- 
found that  even  the  human  germs  which  they  contain  bear  a  trace 
of  it  and  develop  abnormally.  But  these  germs  and  the  human 
beings  which  they  become,  may  undergo  this  abnormal  develop- 
ment without  having  been  infected  by  the  microbe  of  syphilis,  and 
without  ever  having  shewn  an  actual  syphilitic  lesion. 

In  the  second  place  this  original  vitiation  of  the  human  germ 
may  result  from  other  causes  than  syphilis  of  the  parents.  Syphilis 
is  the  most  common  cause,  and  it  is  to  this  that  the  malformation 
should  first  draw  attention,  but  the  relation  of  these  deformities 
to  syphilis  is  not  absolute. 


MAXILLARY    MALFORMATIONS. 

Defects  in  the  formation  of  the  jaws  are  commonly  seen  in  the 
subjects    of   heredo-syphilis.      The    most   common    is    prognathism 


(i2 


THE    TEETH. 


of  the   lower  jaw,   which    cannot   when 


Fig.  23.     Malformation    of    superior    maxilla. 
(Model    and    plate    from    Chompret.) 


at  rest  enclose  itself 
within  the  upper  jaw 
and  projects  beyond 
it.  This  causes  the 
chin  to  be  too  long 
and  prominent. 

At  other  times  the 
upper  maxilla  is  not 
level,  and  the  front 
teeth  do  not  touch 
when  the  mouth  is 
closed  (Fig.  23), 
This  defect  of  form  often  accompanies  prominence  of  the  supra- 
orbital parts  of  the  frontal  bone  and  incomplete  development  of  the 
nose  and  upper  maxilla ;  a  combination  causing  "lunar  crescent  pro- 
file." This  hollow  profile,  in  place  of  the  usual  projecting  one,  is 
one  of  the  most  common  characteristics  of  hereditary  syphilis. 

When  prognathism  of  the  lower  jaw  is  slightly  marked  the  art 
of  the  dentist,  by  making  the  teeth  converge,  may  artificially  render 
the  semi-circle  which  they  describe  possible  of  enclosure  within  the 
arcade  of  the  superior  maxilla.  But  this  is  evidently  all  that  can  be 
attempted  in  such  a  case,  for  we  are  concerned  with  an  anomaly 
of  development  and  not  with  an  active  lesion  capable  of  benefiting 
by  any  medical  treatment. 

Prognathism  of  the  upper  maxilla  is  much  more  rare :  a  remark- 
able example  is  given  of  this  in  Fig.  103.  The  jaws  being  closed, 
the  thumb  could  be  inserted  between  the  upper  and  lower  dental 
arcades.    In  this  case  the  shape  of  the  head  was  phenomenal. 


DEFECTS    OF   DENTAL   IMPLANTATION. 


Defects  of  implantation  of  the  teeth  are  somewhat  rare  in  syphilis 
and  they  must  be  very  marked  indeed  in  order  to  establish  the  pres- 
ence of  syphilis  with  any  probability.  Some  times  one  sees  teeth  dis- 
placed forwards  in  one  or  part  of  the  jaw,  the  two  external  incisors 
being  superposed  on  the  canines.  A  large  molar  has  been  seen  in 
the  middle  of  the  palate  {E.  Fournier),  emerging  from  an  abnormal 
cavity.     Such  cases  are  very  rare. 


THE    TEETH. 


65 


DEFECTS    IN    NUMBER. 

Very  rarely  teeth  arise  from  supplementary  buds,  "reduplicated 
teeth".  This  reduplication  is  more  often  apparent  and  is  due  to  the 
preservation  of  teeth  of  the  first  dentition.  Adults  sometimes  pre- 
serve all  the  teeth  of  the  first  dentition  in  one  or  both  jaws,  inside 
the  row  of  second  teeth;  but  more  often  only  one  or  two  teeth 
survive.  This  is  seen  without  the  least  evidence  of  syphilis  in  the 
parents. 

DEFECTS   IN   SIZE. 

Defects  in  size  of  the  teeth  are  more  characteristic  of  hereditary 
syphilis,  but  do  not  necessarily  imply  it.  Usually  two  symmetrical 
teeth  are  dwarfed,  generally  the  upper  lateral  incisors.     They  are 


Fig.   24.      True    Hutchinson's   teeth. 
(Jeanselme's    patient.       Photo    by    Noir6.) 


well  formed,  with  good  enamel,  but  "doll's  teeth."  There  are  also 
teeth  described  as  "rice  grains."  These  have  been  arrested  in  devel- 
opment, as  the  individual  as  a  whole  may  be. 


t4 


THE   TEETH. 


DEFECTS    IN     SHAPE. 

Defects  in  the  shape  of  the  teeth  are  the  most  frequent  and  most 
•characteristic  in  hereditary  syphiHs.  They  may  be  classified  in  sev- 
eral ways: 


Hutchinson's  teeth.  Hutchinson  described  as  characteristic  of 
syphilis,  the  triad:  Eye,  ear  and  teeth:  the  eye  affected  with 
interstitial  keratitis  or  choroido-retinitis ;  the  ear  with  deafness 
by  ossification  of  the  tympanum  ;^  teeth  with  concave  crescent 

shaped  borders  directed 
inwards  towards  the 
median  line  (Fig.  24). 
These  true  Hutchinson's 
teeth  are  rare. 

Pitted,  furrowed  or 
rusted  teeth.  These  are 
the  most  common,  and 
chiefly  affect  the  four 
upper  incisors,  especially 
the  two  median.  Some- 
times the  anterior  surface  has  the  appearance  of  a  soft  mass  rid- 
dled with  hail  stones.  These  marks  are  greenish,  brown  or 
yellow  ochre  colour  (Figs.  26  and  27). 

Sometimes  the  teeth  are  striated  transversely  by  irregular  fur- 
rows where  the  enamel  is  absent,^  and  the  dentine  appears  yellow 
(furrowed  or  rusted  teeth).  Everyone  has  seen  this  lesion  which 
popular  opinion,  often  justly,  attributes  to  "convulsions  in 
infancy."  Sometimes  a  child  with  hereditary  syphilis  already 
bears  teeth  of  the  second  dentition  marked  in  their  germinal  stage 
and  has  presented  a  mild  attack  of  those  convulsive  crises  which 
•destroy  so  many  heredo-syphilitic  infants. 

These  dental  lesions,  which  are  most  common  in  hereditary 


Fig.  25.     Hutchinsonian    teeth. 
(Chompret's    collection.) 


^  Translator's  Note. — Hutchinson  attributed  the  lesion  of  syphilitic 
deafness  to  a  neuritis  of  the  auditory  nerve.  Fournier  regards  it  as  a 
lesion  of  central  origin  (Vide  "La  Syphilis  Hereditaire  tardive"). 

2  Fournier  points  out  that  the  enamel  is  present  in  the  early  stages,  as 
the  lesion  is  really  a  malformation  and  not  a  true  erosion. 


THE    TEETH. 


6S 


syphilis,  may  occur  by  themselves  or  in  association  with  those 
which  it  remains  to  examine. 


4J^  ^h\  m 


Kg.    26.     Pitted    and   striated    teeth. 
(Chcnipret's    collection.) 


Conical,  "Screw  driver"  and  "fish  teeth."     The  transverse  bars, 
commonly  observed  on  the  anterior  surface  of  the  incisors,  may 


Fig.  27. 


Spotted,    rusted,    striated,     deformed    teeth. 
(Chonipret's   collection.) 


also  occur  on  the  whole  circumference  of  the  tooth.     This  is  then 
formed  of  two  or  three  conical  segments  which  seem  to  arise  one 


66 


THE   TEETH. 


Fig.  28.     Striate    and    comet    shaped    teeth. 
(Chompret's    collection.) 


from  the  other,  like  two  or  three  cones  stacked  one  within  the  other. 

The  lesion  may  be 
more  marked,  two- 
thirds  of  the  tooth 
being  normal  and  the 
terminal  third  with 
the  free  border,  small, 
dirty  yellow  and 
often  marked  with 
black  spots  ( Screw 
driver  tooth  of  A. 
Fournier).  At  other 
times  one  or  more  incisor  teeth  or  canine  lose  their  shape  and 
their  enamel  and  form  simple  irregular  points,  often  sharp  like  the 

teeth  of  a  fish  (A.  Four- 
nier). See  a  canine  in 
Fig.  26. 

Changes  in  the  molar 
teeth.  The  changes  in 
the  molar  teeth  are  very 
special  and  nearly  al- 
ways the  same.  Up  to 
a  certain  level  the  teeth 
are  normal,  covered 
with  enamel,  and  of  normal  form  and  size :  then  the  enamel  sud- 
denly ceases  and  the  tooth  loses  a  millimetre  in  thickness.  The 
cusps  are  yellow  and  irregular.     Later  on,  when  the  individual 


Fig.  29.     Screw-driver    teeth 
(Chompret's    collection.) 


rn:ii;:^^^iB 


Fig.  30.     Changes    in    molar    teeth.      Teeth    with    cusps    deprived    of    dentine.      On 

each  side  of  the  figure,  the  same  teeth  after  wearing  away  of  the  cusps. 

(Chompret's    collection.) 


grows  old,  the  part  of  the  tooth  deprived  of  enamel  is  worn  away 
and  the  tooth  reduced  in  length  to  the  point  where  the  enamel  ceases. 


THE   THROAT. 
PALATE— SOFT    PALATE— PHARYNX. 

The  throat  presents  few  affections  which  concern  the  dermatolo- 
gist, if  all  those  which  the  practitioner  should  be  acquainted  with^. 
but  which  belong  to  general  medicine,  are  omitted. 

/  shall  consider  successively   indurated  chancre^ 
of  the  tonsil I  Tonsillar      chancre  p.  67 

Secondary  syphilides  of  the  fauces  and  soft  palate    Mucous      patches  .  p.  6S 

Tertiary  syphilides  which  in  these  regions  may^ 
assume    two    formSj   the   diffuse  gummatous   /orwr  Diffuse  gummata  .  p.68r 
with    superficial   ulcerations J 

.    .   .  and  gumma  of  the  soft  palate  which  ends^  Perforation   of   the 
in  perforation j     palate P-69. 

To  these  two  lesions  must  be  added  ulcerating^  Syphilitic    ulcer    of 
diffuse  pharyngeal  gummata J      the    pharynx  .    .  p.  70^ 

Lastly  there  exists  a  local  tuberculosis  which  may^ 
take  two  forms,  ulcerative  and  papillomatous,  f/j^  tuberculosis  of  the 
latter  more  commonly J      P^'^te p.  7Qf 

We  shall  confine  ourselves  in  this  chapter  to  a  brief  study  of  these 
affections. 

INDURATED    CHANCRE. 

Indurated  chancre  of  the  tonsil  is  never  diagnosed  at  first.  It  is 
nearly  always  regarded  at  first  as  an  angina,  and  this  error  may- 
be continued  during  its  whole  duration.  The  peculiarity  of  this 
so-called  angina  is  that  it  remains  unilateral. 

The  tonsil  is  doubled  or  tripled  in  size:  it  may  touch  the  uvula 
and  cross  the  middle  line.  It  forms  a  hard  tumour  with  a  plain 
surface  like  a  plateau  and  often  surrounded  or  covered  with  grey 
fibrinous  membranes. 

The  symptoms,  less  marked  than  in  angina,  are  more  severe 
than  in  chancres  situated  elsewhere.  There  is  dysphagia  especially. 
Chancre  of  the  tonsil  lasts  for  six  weeks  or  two  months  and  grad-^ 


68  THE    THROAT. 

ually  disappears.     Sometimes  mucous  patches  of  the   soft  palate 
follow  it  without  any  interval. 

The  chief  characteristic  of  the  indurated  chancre  is  the  satellite 
gland  situated  under  the  middle  of  the  sterno-mastoid  muscle 
(p.  251).  Its  size  is  much  increased:  it  is  visible  to  the  eye,  sensible 
to  touch  and  pathognomonic  even  at  a  distance  (Vidal).  It  dimin- 
ishes and  disappears  with  extreme  slowness  and  may  be  seen  after 
4  or  5  months.     It  may  assist  retrospective  diagnosis. 

MUCOUS    PATCHES. 

Mucous  patches  of  the  throat  are  one  of  the  most  frequent  and 
most  pathognomonic  signs  of  secondary  syphilis.  They  may  be 
few,  abundant  or  profuse.  They  may  occur  on  the  anterior  pillars, 
the  uvula  or  soft  palate  as  red  erosions  circled  with  grey.  They  are 
also  found  more  or  less  disseminated  on  the  tongue,  gums  and 
floor  of  the  mouth.  When  they  are  confluent,  which  is  not  uncom- 
mon, they  line  the  pillars  and  soft  palate  with  exulcerative  lesions, 
the  grey  borders  of  which  form  a  continuous  polycyclic  festoon. 
Nothing  is  more  characteristic  than  these  lesions.  They  are  con- 
temporary with  the  eruptions  of  secondary  syphilis — roseola  and 
papules.  They  may  arise  neaidy  simultaneously  or  in  crops,  the  first 
crops  being  always  the  most  severe  and  composed  of  the  most 
numerous  lesions.  The  same  eruption  occurs  in  the  larynx,  causing 
the  raucous  voice.  They  generally  last  for  6  to  10  weeks,  fresh 
patches  forming  when  the  first  disappear.  The  eruption  may  thus 
continue  for  some  time  and  be  reproduced  after  it  had  apparently 
terminated. 

The  traditional  treatment  of  mucous  patches  consists  in  cauter- 
isation with  nitrate  of  silver.  Their  proper  treatment  is  that  of 
-secondary  syphilis  (p.  650). 

IMucous  patches  are  contagious  and  the  saliva  of  persons  w^ho 
"have  them  is  contaminated.  Ejection  of  saliva  during  a  medical 
examination,  a  fit  of  coughing,  etc.,  has  in  rare  cases  given  rise 
to  contagion. 

DIFFUSE    GUMMA. 

Like  nearly  all  gummatous  lesions  of  the  mouth  these  are  most 
often  diagnosed  in  the  period  of  ulceration,  for  the  onset  is  pain- 


THE    THROAT.  69 

less  and  their  advanced  state  is  more  characteristic.  These  gummata 
are  generally  situated  on  the  soft  palate  and  on  one  side  only.  They 
form  an  irregular  group  of  small  ulcerations,  with  a  greenish 
yellow  base,  from  one  to  three  millimetres  in  depth,  of  sub- 
acute evolution,  characterised  only  by  some  permanent  discomfort 
and  dysphagia.  The  ulcers  are  3  to  4  millimetres  in  diameter,  irreg- 
ularly rounded  and  situated  on  an  indurated  flat  mass,  common  to 
all,  which  constitutes  the  diffuse  gumma,  each  necrotic  focus  of 
which  has  given  rise  to  a  distinct  ulcer. 

This  lesion  usually  occurs  from  3  to  10  years  after  the  chancre, 
but  sometimes  after  a  long  period.  It  is  amenable  to  mixed  intense 
treatment  by  injections  of  grey  oil  and  alkaline  iodides,  which 
heal  the  lesion  in  three  weeks.  This  forms  a  certain  means  of  dif- 
ferential diagnosis  when  there  is  a  doubt  between  diffuse  gumma 
and  epitheliomatous  or  tuberculous  lesions  in  the  same  situation. 

PERFORATION  OF  THE  SOFT  PALATE. 

The  lesion  which  causes  perforations  of  the  soft  palate  is  of  the 
same  nature,  the  same  date  and  the  same  evolution  as  the  preceding. 
There  are  no  premonitory  symptoms,  and  when  the  patient  com- 
plains the  perforation  is  made.  In  appearance  it  is  a  small  irregular 
ulceration  with  a  greenish  yellow  base.  A  probe  passes  through  it 
into  the  nasal  fossse. 

The  perforation  is  made  by  a  small  gummatous  tumour  usually 
situated  at  the  junction  of  the  hard  or  soft  palate,  the  softening  of 
which  takes  place  without  pain  and  which  finally  opens.  Usually 
the  perforation  is  single.  When  the  patient  is  extremely  negligent, 
the  ulceration  enlarges  and  the  loss  of  substance  may  be  enormous. 
It  is  always  irreparable. 

]\Iixed  treatment  should  be  rapid,  intense  and  long  continued 
(p.  650).  Under  its  action  the  necrosed  part  is  eliminated,  the  ulcer- 
ation heals  and  cicatrisation  is  produced;  but  the  loss  of  substance 
remains. 

When  it  is  very  small  and  well  cicatrised  angular  cauterisations 
with  the  galvano-cautery,  repeated  every  month,  will  provoke  pro- 
gressive cicatricial  atresia.  But  this  should  only  be  attempted  on 
a  lesion  which  is  perfectly  healed.  In  more  severe  cases  reflux  of 
food  through  the  nose  and  troubles  of  phonation  require  the  patient 
to  wear  an  obturator. 


70 


THE    THROAT. 
SYPHILITIC   ULCER   OF  THE  PHARYNX. 


A  lesion  of  the  same  kind,  the  same  date  and  the  same  nature 
may  be  situated  in  the  back  of  the  throat.  On  making  the  patient 
open  his  mouth  wide  and  utter  a  deep  sound,  which  raises  the  soft 
palate,  one  sees  at  the  back  of  the  pharynx  a  lateral  ulceration, 
'often  elongated  vertically,  with  irregular  sloping  and  reddened  bor- 
•ders ;  the  base,  which  is  covered  with  a  greenish  yellow  mammillated 
•scab,  is  depressed.  The  symptoms  are  slight,  and  a  rapid  cure  is 
.obtained  by  mixed  intense  treatment. 

All  these  tertiary  lesions  arise  from  syphilis  unknown  to  the 
patient  and  not  treated ;  or  syphilis  very  incompletely  treated,  to 
which  the  patient  pays  no  attention,  because  he  thinks  it  has  been 
extinct  for  some  time. 

LUPUS    OF  THE   PALATE. 


.t^<£iiS>' 


Lupus   of  the   soft   palate   and   pharyngeal   isthmus   is   only   the 
prolongation  to  the  mouth  of  lupus  of  the  gums,  lips  or  face.     It  is 

only    seen    in    cases    of    extreme 
-...^i-,^^,  _.  gravity     neglected     for     years.     It 

occurs  in  the  papillomatous,  fun- 
gous, hypertrophic  form,  analogous 
in  symptoms,  course  and  evolution 
to  gingival  lupus  (p.  41).  The 
treatment  is  the  same  for  lupus  of 
any  other  part  of  the  mouth. 

ULCERATIVE    PHARYNGEAL 
TUBERCULOSIS. 

This  is  a  rare  affection  analogous 
in  form,  objective  type  and  evolu- 
tion   to   tuberculous    ulceration    of 
the  tongue  (p.  51),  or  the  mucous 
surface  of  the  lips  (p.  83). 
Here  as  there  it  is  a  sinuous,  narrow,  often  linear  ulceration, 
with  a  hard  border;  callous,  sometimes  velvety,  sharply  cut,  with 
a  yellow  base  stippled  with  red  and  bleeding  easily. 


ng.31.     Lupus    of    the    palate.      (Gu- 

yot'a    patient.     St.    Louis    Hosp. 

Museum,     No.     667.) 


THE    THROAT.  71 

The  tuberculous  ulcers  have  always  accentuated  functional  symp- 
toms and  are  sensitive  to  the  least  touch. 

Treatment  is  the  same  as  for  other  tuberculous  ulcerations  of 
the  mouth  (p.  51). 


THE  INTERNAL  SURFACE  OF  THE  CHEEKS. 

The  dermatological  pathology  of  the  internal  surface  of  the 
cheeks  coincides  to  a  great  extent  with  that  of  the  mouth  in  general : 
For  instance,  ulcero-membranous  stomatitis  (p.  37),  tuberculous 
lupus  of  the  buccal  mucosa  (p.  41).  The  inside  of  the  cheeks  par- 
ticipates in  the  evolution  of  dermatological  affections  of  the  gum, 
in  mercurial  gingivitis  (p.  57).  etc.;  and  even  when  the  whole  of 
the  cheek  presents  lesions  having  a  particular  physiognomy,  these 
are  often  only  an  epiphenomenon  of  buccal  lesions:  for  instance, 
leucoplasia  (p.  39);  or  more  general  eruptions  such  as: — lupus 
erythematosus  (p.  18)  and  lichen  planus  (p.  553)  ',  or  general  dis- 
eases such  as  syphilis. 

For  these  reasons  this  chapter  will  be  short. 


/    shall    consider    the    interdental    excrescences\  Interdental  Ex- 

caused  hy  the  disappearance  of  one  or  more  teeth  .  j      crescences     .    .    .   p.  72 

The  leucoplasic  patches  of  smokers;  their  rz'o/;/-| 
tion  and  epitheliomatous  degeneration ^  Leucoplasia  ....  p.  73 

The  grey  aborescent  patches  of  lupus  erythema-'] 
tosus,  which  constitute  perhaps  the  most  localised  \^^^^'^^  Erythemato- 
dermatosis  of  the  region ^      ^"^      P" '''* 

Finally,     the     greyish     Hue     finely     quadrilatcd\ 
patches  of  lichen  planus |  Lichen     planus   .    .  p.  7J 

The  divers  vielanodermias  of  the  same  situation^ 
have   been   mentioned.     For  melanodermia   of  the 
inner  surface  of  the  cheeks  ref'>.r  to  what  I  have 
written   in    the   article   on    the    mouth    in   general 

(^  42)  


.  Melanodermia     .    .  p.  74. 


INTERDENTAL   EXCRESCENCES. 

In  the  place  of  an  absent  tooth,  generally  a  large  molar,  it  is  not 
uncommon  to  see  the  mucosa  of  the  inner  surface  of  the  cheek 
form  a  large  bud,  or  excrescence,  of  a  definite  form,  which,  when 
the  jaw  is  at  rest,  exactly  fills  the  place  of  the  missing  tooth. 
This  fact  should  be  known,  so  as  to  avoid  confusion  of  these 
tuberosities  with  some  neoplasm.  These  projections  are  injured 
at  each  movement  of  the  jaw,  or  pinched  between  the  teeth  dur- 


THE  INTERNAL  SURFACE  OF  THE  CHEEKS.     73. 

ing  mastication,  and  become  eroded  and  may  even  form  the  point 
of  origin  of  an  epithelioma.  They  can  only  be  made  to  disap- 
pear by  wearing  a  dental  apparatus  to  replace  the  absent  tooth. 

LEUCOPLASIA. 

Buccal  leucoplasia  has  been  studied  above  (p.  39),  but  its  localisa- 
tions on  the  inner  surface  of  the  cheeks  often  presents  a  special 
physiognomy. 

The  lesions  are  situated  on  the  internal  surface  of  the  commis- 
sures, where  they  form  grey,  hypertrophic,  radiating  patches 
which  have  been  called  "smoker's  patches."  Total  and  pro- 
longed avoidance  of  tobacco  does  not,  however,  always  cause 
their  disappearance. 

True  leucoplasia  appears  to  be  only  a  further  degree  of  hyper- 
keratosis. The  raised,  white,  circumscribed  patches  may  be  sit- 
uated on  the  commissures  or  on  any  part  of  the  inner  surface  of 
the  cheek.  Their  evolution  and  characters  are  those  of  buccal 
leucoplasia  in  all  localisations.  In  buccal  leucoplasia  it  is  often 
on  patches  in  this  situation  that  epithelioma  developes.  It 
appears  then  on  the  leucoplasic  patch  of  the  radiating  "sea-anemone" 
type. 

This  super-leucoplasic  epithelioma  may  be  of  a  severe  degree. 
I  have  dealt  with  its  treatment  and  that  of  leucoplasia  on  pp.  52 
and  40. 

BUCCAL    LICHEN    PLANUS. 

Lichen  planus  of  Wilson  (p.  553)  is  often  situated  on  the 
mucosa  of  the  cheeks,  tongue  or  soft  palate.  It  occurs  there  in 
the  form  of  bluish  arborescences  resembling  thin  cicatricial 
tracts  which  subdivide  and  intersect.  Certain  of  these  Hues 
enlarge  in  places  to  form  small  flat,  grey,  slightly  raised  papules, 
sometimes  very  numerous,  in  the  midst  of  a  network  in  which 
they  are  included,  as  islets.  Buccal  lichen  planus  affect  the  same 
form  and  symptoms  on  the  tongue,  palate,  etc. ;  but  in  the  mouth 
it  is  more  common  on  the  inner  surface  of  the  cheeks  than  else- 
where. 

Lichen  planus  of  the  mouth  is  only  one  localisation  of  lichen 
planus  of  all  mucous  membranes,  and  only  has  a  symptomatic. 


74  THE  INTERNAL  SURFACE  OF  THE  CHEEKS. 

value ;  lichen  planus  of  all  situations  being  without  special  treat- 
ment and  healing  only  in  several  months.  The  lesions  of  the  cheeks 
may  survive  those  of  the  body.  They  are  said  to  have  been  observed 
alone  in  some  cases.  Certain  dermatologists  regard  as  lichen  planus 
all  non-syphilitic  leucoplasia,  but  this  opinion  appears  to  me  to  be 
in  contradiction  with  clinical  facts.  The  evolution  of  essential 
leucoplasia  is  very  different  to  that  of  lichen  planus  in  any  situation. 

MELANODERMIA. 

In  the  chapter  on  the  mouth  in  general  I  have  spoken  succinctly 
of  melanodermia  and  of  vitiligo  (p.  42).  These  lesions  are  especially 
seen  on  the  inner  surface  of  the  cheeks.  In  such  a  concise  epitome 
as  this  I  have  nothing  further  to  say.  I  shall  deal  with  melanoder- 
mia in  general  on  page  611. 

LUPUS   ERYTHEMATOSUS. 

Lupus  erythematosus  is  rarely  observed  in  the  mouth,  but  always 
has  an  elective  localisation  for  the  inner  surface  of  the  cheeks.     It^ 
forms  one  or  more  irregular  patches,  slightly  raised,  indurated,  red. 
and  studded  with  white  patches  of  hyperkeratosis  and  traumatic 
erosions  caused  by  the  teeth. 

This  has,  in  certain  cases,  been  described  as  the  only  localisa- 
tion of  the  disease,  but  in  the  immense  majority  of  cases  it 
accompanies  lupus  erythematosus  of  the  face,  scalp  and  body. 

Its  progress  and  evolution  are  those  of  ordinary  lupus  erythe- 
matosus. Radio-therapy  should  be  of  more  value  than  in  lupus 
erythematosus  of  the  skin,  for  it  can  be  applied  both  internally  and 
externally  at  the  same  time,  and  it  is  known  that  high  doses  of  the 
X-rays  are  required  to  act  on  lupus  erythematosus  (p.  19). 


THE  LIPS. 

The  dermatological  pathology  of  the  lips  is  somewhat  complex, 
for  the  lips  present  two  surfaces,  the  one  cutaneous,  the  other 
mucous,  and  a  free  border,  of  which  the  dermatological  manifesta- 
tions are  peculiar:^ 

In  the  child  the  commissures  present  two  syntA 

metrical    points    of    chronic    irritation    known    o^  I  Perleche p.  75 

"perleche" j 

The  corner  of  the  lips  in  the  adult  often  shews^  •,-.,.,. 
vesicular  clusters  of  febrile  herpes J- Febrile    ..-rpes  .    .  p.  76 

The  red  border  of  the  lips  is  sometimes  fragile-^  Fissured  eczema  of 

and  shews  fissures  and  eczema j      the  red  border  .  p.  77 

The  cutaneous  border  also  shews  eczema,  often-^  Eczema  of  the  cu- 

traumatic j      taneous  border.    .  p.  78 

Sometimes  milium  occurs Milium      p.  79 

The  lips  may  he  the  scat  of  hard  chancre  .    .   .    Indurated    chancre    p.  79 
.   .   .  and  also  of  mucous  patches Mucous    patches.    .  p.  80 

The  internal  surface  of  the  lips  presents  a  ter-^ 
tiary  hypertrophic  syphiloma |  Tertiary    syphiloma  p.  80 

The   same   region   may   present   the    old   buccal\  Non-syphilitic    leu- 

psoriasis;   better   termed   non-syphilitic   leucoplasiaJ     coplasia p.  81 

.    .    .  zvhich  often  ends  in  epithelioma Epithelioma  .  .    .    .  p.  81 

The  lip,  finally,  shews  tuberculous  lupus  of  the^ 
.    .•>,        .              J    ;    A     *     i.;  •     /  tuberculous     lupus  p.  82 

papillomatous  and  hypertrophic  form J  f      t- 

.    .    .  and  an  ulcerative   tuberculosis,  a«a/ogOMj"]  Tuberculous    ulcer- 
to  that  of  the  tongue }      ation p.  83 

PERLECHE. 

Common  perleche  is  an  intertrigo  of  the  labial  commissures ;  and 
intertrigos  are  streptococcic  impetigos  localised  in  the  natural  folds. 
Perleche  is  thus  a  commissural  impetigo.  It  may  be  due  to  a  strep- 
tococcic salivary  infection,  or  accompany  lesions  of  impetigo  of 
the  face. 

The  lesion  is  constituted  in  each  commissural  angle  by  one  or 
more  fissures  of  the  fold  surrounded  by  two  corresponding  surfaces 
of  epidermis,  which  is  macerated  and  of  a  white  or  violet  colour. 

1  All  the  hairy  diseases  of  the  lips  will  be  studied  in  the  chapters  on  the 
moustache,  p.  142,  and  beard,  p.  i53- 


ye  THE    LIPS. 

On  the  skin  perleche  may  be  continued  by  a  lesion  of  true  impetigo, 
radiating  like  a  bird's  claw,  or  by  a  lesion  of  powdery  scabs  or  fine 
scales  (Vide  Pityriasis  simplex  faciei,  p.  lo).  When  left  to  itself 
this  lesion  may  last  for  months.  It  disappears  slowly  and  may 
recur. 

Perleche  is  not  only  contagious  like  impetigo,  but  is  also  epidemic. 
It  is  a  disease  of  schools,  no  doubt  transmitted  by  the  habit  of  suck- 
ing pen-holders.  This  epidemic,  which  is  nearly  always  connected 
with  an  epidemic  of  pityriasis  of  the  same  microbial  nature,  is  of  no 


FLg.  32.     Perleche.     Commissural  Impetigo  or  Streptococcic  intertrigo. 
(Jacquet's    patient.     Photo    by    Dubray.) 

great  mportance.    The  streptococcic  nature  of  the  diverse  lesions  is 
shewn  by  the  methods  of  culture  for  common  impetigo  (p.  8). 

The  treatment  of  perleche  is  the  same  as  for  impetigo ;  by  fric- 
tion with  sulphate  of  zinc  (i  per  cent.)  or  nitrate  of  silver  (5  per 
cent.),  and  applications  of  zinc  ointment.  When  the  perleche  is 
accompanied  by  radiating  cutaneous  lesions  the  following  is  useful : — 

Oil  of  cade laa.  5  grammes  1     aa.  gr.  80 

Oxide  of  zinc I  J 

Vaseline T  ^„  «  T    t- 

Lanohne j  J 

FEBRILE  HERPES. 

Febrile  herpes  is  seen  most  often  on  the  cutaneous  surface  of 
the  lower  lip,  near  the  commissure;  but  it  may  occur  on  all  the  sur- 
rounding regions. 

It  may  be  menstrual  and  then  often  periodic;  or  it  may  coincide 
with  tonsillar  herpes,  simple  angina,  or  even  general  malaise,  such 
as  migraine.  Its  critical  value,  so  much  remarked  by  the  older 
physicians,  remains  true  in  many  acute  infectious  states,  especially 
in  pneumonia. 


THE   LIPS, 


77 


The  cluster  of  herpes  is  constituted  by  6  to  lo  small  turbid, 
oblong  vesicles,  united  side  by  side,  but  irregularly  in  several  small 
groups.  The  vesicles  are  of  equal  size,  2  or  3  millimetres  in  diam- 
eter and  have  the  form  of  half  an  ^^'g  cut  in  its  long  axis.  The  size 
and  uniformity  of  the  vesicles  and  their  topographical  distribution 
are  the  principal  elements  in  diagnosis.  These  vesicles  arise 
together  and  develop  at  the  same  rate,  situated  on  a  small  common 
erythematous  placard,  which  disappears  after  the  third  day. 

If  the  vesicles  of  herpes  are  opened  by  scratching,  their  (horny) 
cupola  is  replaced  by  a  serous  crust  under  which  the  lesion  heals. 
In  six  or  eight  days  it  has  disappeared. 

No  treatment  modifies  the  spontaneous  evolution  of  herpes.  It 
is  always  accompanied  at  first  by  slight  adenitis. 


FISSURES.      ECZEMA   OF  THE   RED   BORDER  OF  THE  LIPS. 


Under  the  influence  of  cold  and  wind  some  persons  are  liable  to 
an  inflammatory  condition  of  the  red  border  of  the  lips,  which  is 

both  painful  and  distressing. 
The  pain  is  especially  severe  on 
moving  the  lips  and  when  acid 
substances  or  pepper  are  eaten. 
The  lesion  resembles  a  burn, 
the  red  border  of  the  lips  des- 
quamating and  appearing  cov- 
ered with  debris  resembling 
onion  peel.  Here  and  there 
there  are  antero-posterior  or 
transverse  fissures,  sometimes 
deep  and  painful  and  exuding  a 
drop  of  serum  or  blood. 

This  condition  is  most  fre- 
quent in  winter  and  is  often 
accompanied  by  chilblains.  It 
may,  however,  occur  by  itself 
even  in  the  summer  and  behave 
like  an  eczema  (Fig.  33).  In 
this  case  it  is  often  connected  with  an  acid  reaction  of  the  saHva 
or  with  an  eczema  of  the  cutaneous  border  of  the  lips  (p.  78). 


rig:.  33.     Chronic     eczema     of     the     lips. 

(A.    Fournier's    patient.      St.    Louis 

Hosp.    Museum,    No.    849.) 


yS  THE    LIPS. 

When  it  consists  of  an  erythema  a  frigore,  glycerinated  prepar- 
ations are  often  successful : — 

Glycerole  of  starch    ....  30  grammes  5J 

iartanc   acid     ...      1     ^a.  .30  centigrammes     j       aa.  gr.  5 

Resorcine       J 

This  reheves  the  patient  and  often  cures  in  a  few  weeks. 
When   there   are   lesions    connected   with    external    eczema    or 
salivary    acidity,    alkaline   treatment,    either   buccal    or    gastric,    is 
indicated.    Locally,  glycerole  of  tar  may  be  applied.    Alternating 
with  nitrate  of  silver  (i  in  15). 

Liquid  tar 5  grammes — 5i  ss. 

Fluid  extract  of  panama,  to  saponify. 

Glycerole   of  starch 30  grammes — 5i 

ECZEMA    OF  THE   CUTANEOUS    BORDER   OF    THE   LIPS. 

This  is  one  of  the  most  distressing  and  rebellious  affections.  It 
is  situated  exactly  at  the  point  where  the  skin  joins  the  semi-mucosa 
of  the  red  border  of  the  lips. 

The  lesion  may  affect  both  lips,  but  is  often  situated  on  the  lower 
lip  alone.  It  may  be  accompanied  by  the  desquamating  and  fissured 
condition  of  the  red  border  of  the  lips  just  described. 

It  may  vary  from  three  millimetres  to  about  a  centimetre  in  width. 
Its  border  is  sharp  on  the  semi-mucosa,  but  ill  defined  on  the  skin. 
On  the  surface  the  horny  epidermis  is  absent  and  the  excoriated  sur- 
face is  yellowish  red,  moist,  and  covered  with  crystalline  crusts. 
At  certain  places  small  vertical  fissures  are  seen,  more  or  less  dis- 
tinct and  painful.  The  lesion  is  continually  smarting,  especially 
during  or  after  meals. 

The  duration  of  this  affection  is  very  long.  It  is  recurrent  and 
paroxysmal,  and  often  developes  gradually  by  a  polycircinate 
border. 

It  is  perhaps  a  streptococcic  lesion  and  not  an  eczema^. 

Treatment  is  unsatisfactory;  simple  protective  ointments  are 
insufficient  and  followed  by  no  results.  I  have  seen  applications  of 
tincture  of  iodine  (10  per  cent.)  modify  the  extension  of  this  der- 
matitis. Between  daily  applications  of  this  mixture  zinc  ointment 
is  applied.  Nitrate  of  silver  (20  to  30  per  cent.)  applied  on  a  brush 
gives  equally  good  results. 

*  According  to  the  latest  works  of  the  French  school — Besnier,  Brocq, 
Veillon,  and  Sabouraud,  the  term  eczema  should  be  confined  to  a  process 
characterised  essentially  by  finely  vesicular  lesions,  primarily  amicrohial 
by  all  the  actual  means  of  investigation. 


THE   LIPS.  79 

As  in  the  analogous  cases  the  salivary  and  gastric  reactions  should 
be  studied  and  remedied  when  necessary.  Finally,  eczema  of  trau- 
matic origin,  which  is  described  below,  must  be  borne  in  mind. 


ARTIFICIAL    ECZEMA. 

In  artificial  eczemas  of  the  lips,  whatever  objective  type  they  affect, 
the  physician  should  always  think  of  traumatic  dermatitis  often 
caused  by  pencils  of  rouge,  and  tooth  pastes,  especially  pastes  and 
powders  with  salol.  The  odour  of  salol  in  these  pastes  and  powders 
is  easily  recognizable.  The  cause  being  discovered  and  removed, 
simple  treatment  causes  disappearance  of  the  lesions.  Equal  parts 
of  oxide  of  zinc  and  fresh  lard,  or  in  acute  cases  fresh  oil  of  sweet 
almonds  is  sufficient. 

MILIUM. 

Exactly  at  the  margin  of  the  red  border  of  the  lips  and  the  skin, 
one  or  two  rows  of  small,  round,  white,  miliary  cysts  may  be  seen, 
constituting  milium.  This  lesion  is  insignificant  and  painless,  but 
the  patient  may  be  alarmed  when  he  discovers  it,  and  a  woman  may 
find  it  disfiguring. 

The  cysts  may  be  easily  destroyed  one  by  one  with  the  fine 
point  of  a  galvano-cautery,  and  after  two  or  three  sittings  a  cure  is 
obtained. 

INDURATED   CHANCRE. 

The  indurated  chancre  may  occur  on  almost  any  part  of  the  lip 
and  is  nearly  always  typical.  It  is  a  raised,  round  lesion  of  car- 
tilaginous consistency,  enclosed  in  the  skin;  with  a  flat,  red,  slightly 
eroded  and  non-suppurating  surface.  The  pre-auricular,  sub-max- 
illary or  sub-hyhoid  glands  may  be  enlarged,  according  to  the  situ- 
ation of  the  chancre. 

The  course,  duration  and  evolution  of  the  lesion  is  typical.  It 
requires  no  local  treatment,  and  such  applications  as  emplastrum 
Vigo  are  unnecessary.  Syphilis  following  extragenital  chancres  has 
not  the  grave  prognosis  which  has  been  suggested. 

The  contagion  from  a  chancre  of  the  lip  is  too  obvious  to  be 
insisted  on,  but  the  patient  should  be  warned  against  the  danger 
of  kissing. 


:8o  THE    LIPS. 

MUCOUS    PATCHES. 

Mucous  patches  may  be  observed  on  the  mucous  surface  of  the 
hps  as  elsewhere  in  the  mouth  and  have  the  usual  characters;  a 
diameter  of  3  to  4  millimetres,  oval  form,  central  depression,  red 
colour  and  grey  borders. 

Commissural  mucous  patches  are  peculiar  and  may  attain  excep- 
tional dimensions.  Their  grey  border  extends  beyond  the  lip  like 
the  commissural  membrane  of  a  bird.  Even  at  a  distance  the  aspect 
is  peculiar.  These  lesions,  which  may  be  seen  at  any  age,  are  very 
common  in  syphilitic  nurslings.  They  usually  accompany  a  florid 
roseola  or  an  abundant  secondary-  papular  eruption  on  the  body, 
which  leaves  no  doubt  as  to  diagnosis.  The  mouth  also  contains 
mucous  patches  of  the  ordinary  type. 

TERTIARY  HYPERTROPHIC  SYPHILOMA. 

The  lips,  especially  the  lower  lip,  may  be  the  seat  of  the  tertiary 
hypertrophic  lesion,  which  occupies  the  whole  surface  of  the  lip  and 
presents  a  great  resemblance  to  the  tertiary  syphilitic  tongue.  The 
mucosa  is  mammillated  and  traversed  by  the  white  cicatrices  of 
former  lesions.  By  the  side  of  these  cicatrices  there  are  often  flat 
red  ulcerations  in  process  of  cicatrisation.  The  lesions  cease  at 
the  red  border  of  the  lips,  which  is  visibly  thickened,  everted  and 
deformed.  There  are  often  commissural  rhagades.  These  lesions 
are  always  accompanied  by  some  salivary  hypersecretion. 

Although  tertiary  lesions  are  reported  to  be  non-contagious, 
great  doubt  prevails  with  regard  to  these,  and  the  patient  should 
be  warned. 

The  spontaneous  evolution  of  these  lesions  is  chronic  and  pro- 
gressive. They  resist  the  usual  anti-syphilitic  methods  and  require 
intense  treatment  by  injections  of  gray  oil  (i  in  40)  twice  daily, 
or  daily  inunctions  with  4  to  6  grammes  (oi  to  oiss)  of  mercurial 
ointment.  Syrup  of  Gibert  (Biniodide  of  ]\Iercury)  in  large  doses 
may  be  given  to  patients  with  a  strong  stomach.  Local  treatment 
must  not  be  neglected:  cauterisation  of  the  ulcers  with  nitrate 
of  silver,  chloride  of  zinc  (i  in  15)  or  chromic  acid  (i  in  5)  give 
excellent  results. 


THE   LIPS.  81 

NON-SYPHILITIC    LEUCOPLASIA. 

This  is  the  old  buccal  psoriasis  already  studded  with  lesions  of 
the  mouth  in  general  (p.  39).  It  has  no  connection  with  psoriasis 
and  does  not  appear  to  be  related  to  syphilis,  although  this  has  been 
stated.  The  previous  occurrence  of  white  smoker's  patches  within 
the  buccal  commissures  is  not  necessary,  but  is  often  observed. 

Buccal  leucoplasia  is  observed  on  the  internal  surface  of  the  lip 
as  on  that  of  the  cheek  and  on  the  mucosa  of  the  gums.  The  lesions 
have  everywhere  the  appearance  of  a  thin  layer  of  coagulated  white 
of  egg,  but  the  patches  are  completely  adherent  to  the  mucosa.  They 
are  slightly  in  relief  and  on  the  surface  are  folded  or  quadrilated, 
according  to  the  region  of  the  mouth  which  they  occupy.  At  the 
commissure  they  are  marked  v/ith  radiating  folds  (crows  feet). 

This  lesion  is  allied  to  the  hyperkeratoses.  It  occurs  at  the  age  of 
20  to  30.  It  is  chronic  and  never  disappears,  but  may  slowly  change 
from  place  to  place,  diminishing  and  increasing.  After  40  or  45 
years  of  age  there  is  a  constant  danger  of  epithelioma.  The 
epitheliomatous  nature  of  the  leucoplasia  itself  has  been 
maintained. 

Treatment  is  almost  nil.  It  is  a  good  rule  either  to  leave  them 
alone  or  to  destroy  them  entirely,  for  half  measures  are  dangerous. 
Scraping  and  the  galvano-cautery  have  been  used.  The  action  of 
the  X-rays  is  certain,  but  difficult  in  application,  and  the  results 
have  not  been  shown  to  be  constant. 

In  medium  cases  we  may  be  content  without  constant  supervision, 
frequent  mouth  washes  with  cupric  water  (St,  Christau)  and  the 
avoidance  of  all  local  irritation,  such  as  tobacco. 


EPITHELIOMA. 

Epithelioma  of  the  lip  may  follow  leucoplasia.  On  a  patch  of 
chronic  leucoplasia  develops  a  flat,  epitheliomatous  swelling  or  a 
projecting  tum.our.  Epithelioma  of  the  lip  may  become  grafted  on 
the  tertiary  syphiloma  previously  described  (p.  80),  It  is  usually 
more  vegetating  than  the  preceding  and  often  more  or  less 
framboesiform. 

Lastly,  epithelioma  may  develop  on  the  border  of  the  lip 
without  being  preceded  by  any  other  dermatological  lesion.     It 


82  THE    LIPS. 

affects,  in  this  case,  the  common  form  of  epithelioma  of  the 
face  (p.  31).  However,  there  are  framboesiform  forms  as  well 
as  ulcerative.  By  pressing  the  epitheliomatous  swelling  between 
the  fingers,  white  filaments  emerge  with  a  few  drops  of  blood. 
These  filaments  are  shewn  by  the  microscope  to  consist  of 
epidermic  cells  and  globes.  In  this  localisation,  on  the  borders, 
of  the  lips,  epithelioma  is  of  less  rapid  progress  than  super- 
syphilitic  or  leucoplasic  epithelioma,  the  gravity  of  which  is 
often  great. 

It  is  impossible  to  pronounce  absolutely  on  the  value  of  the 
X-rays  in  the  treatment  of  epitheliomas  of  these  regions.  I  may 
mention,  however,  that  I  have  treated,  with  my  assistant,  .1/.  Xoirc, 
a  woman  attacked  with  super-leucoplasic  epithelioma  of  the  com- 
missure, which  had  recurred  after  two  operations ;  it  was  adherent 
to  the  jaw  and  regarded  by  the  surgeon  as  inoperable.  An  appar- 
ently complete  cure  was  obtained  in  8  sittings  of  5  units  H.  The 
patient  has  had  no  recurrence  during  5  months  of  observation.  If 
such  results  were  constant  and  permanent  they  would  be  completely 
satisfactory. 

Apart  from  radiotherapy  one  can  only  advise  extensive  excision, 
and  this  proceeding  is  compatible  with  radiotherapy  of  the  cicatrix 
afterwards^. 

LUPUS   OF  THE  LIP. 

Lupus  of  the  deep  surface  of  the  lip  seldom  exists  alone,  but  is 
usually  accompanied  by  lupus  of  the  face,  of  which  it  represents  the 
extension. 

It  is  rarely  ulcerative  at  the  first,  but  usually  hypertrophic  and 
papillomatous.  The  lip  is  doubled  in  thickness  by  hard  oedema, 
and  the  surface  is  fungous  and  papillomatous.  Sometimes  the 
fungosities  are  soft  and  without  tendency  to  ulcerate ;  sometimes 
they  form  hard  papillomata  with  a  tendency  to  hypertrophy  This 
process  is  very  chronic  and  slowly  progressive,  and  extends  to  the 
gums  and  the  cheeks. 

Lupoid  ulceration  is  not  very  deep;  it  is  of  a  yellowish  colour,  and 
suppurates  little.  The  process  never  undergoes  spontaneous  reso- 
lution. 

*  Epitheliomas  of  the  lower  lip  are  not  all  cured  by  radiotherapy 
(Brocq).     Lobulated  pavement  epitheliomas  resist  it   (Darier). 


THE    LIPS.  85 

The  treatment  par  excellence  of  these  morbid  conditions  is  the 
phototherapy  of  Finsen  (p.  21),  to  which  may  be  added  excision  of 
the  hypertropic  processes  with  scissors  or  sharp  spoon.  As  accessory 
measures,  we  may  mention  the  galvano-cautery,  the  first  results  of 
which  are  good,  but  which, as  in  other  cases  of  lupus,  improves  but 
does  not  cure.  We  may  also  mention  the  treatment  of  ulcerations 
by  lactic  acid  or  by  chloride  of  zinc,  the  results  of  which  are  more 
striking  in  the  following  affection. 

TUBERCULOSIS    OF  THE   LIP. 

As  with  the  tongue  and  the  throat,  there  exists  a  gummatous 
and  ulcerative  tuberculosis  of  the  lip  entirely  different  in  appear- 
ance and  evolution  to  lupus  in  the  same  situation. 

Usually  the  lesion  consists  in  an  ulcerated  ragged  fissure,  one 
border  of  which  at  least  is  hard  and  callous.  The  ulceration  is 
sharply  cut  with  a  yellowish  base  studded  with  red  points.  It  sup- 
purates little  and  is  very  sensitive  to  touch.  It  may  be  situated  on  a 
more  or  less  distinct,  deep-seated  tumour.  In  cases  where  one  or 
both  borders  of  the  ulcer  are  callous,  the  subjacent  tumour  may  be 
wanting.  This  lesion  may  accompany  or  follow  tubercle  of  the 
tongue  (p.  51)  and  has  the  same  treatment  and  prognosis,  both  gen- 
eral and  local. 

The  treatment  consists  in  phototherapy,  the  galvano-cautery, 
cauterisation  with  chloride  of  zinc  and  lactic  acid.  The  local  prog- 
nosis is  usually  mediocre,  although  cure  may  be  effected  by  the 
above  measures.  The  general  prognosis  is  bad,  and  should  at  least 
be  guarded,  for  these  lesions,  in  distinction  to  lupus,  generally 
accompany  pulmonary  tuberculosis.  It  is  the  rule  that,  when  pul- 
monary tuberculosis  is  accompanied  by  laryngeal,  labial  or  lingual 
lesions,  the  prognosis  is  bad. 


Staphylococcic    an- 
terior Rhinitis  .  .   p.  85 


THE  NOSTRILS. 

The  pathology  of  the  nostrils  may  be  summed  up  for  the  der^ 
matologist  in  four  chapters,  and,  apart  from  the  morbid  types 
which  we  shall  consider,  everything  else  is  exceptional  or  unim- 
portant. 

(1)  The  first  is  chronic  streptococcic  nasal  »/"- 1  streptococcic    nasal 
pctigo,  which  in  the  child  causes  recurrence  of  im-  r     jj-,^pgtjgQ  p  84 
pctigo    of   the   face J 

With  this  morbid  type  we  shall  study  recurrentYRecurrent     Erysip- 
crysipcloid.  which  may  be  the  result  of  it  .    .       .j     eloid p.  85 

(2)  The  second  of  these  types  is  chronic  an-' 
tcrior  staphylococcic  rhinitis,  arising  from  pustular 
blepharitis  and  causing  pustular  sycosis  of  the 
moustache 

/  shall  say  a  feiv  zvords  concerning   the  exotic\  ^,  . 
,.                71    .     d;  •         I  rRhmoscleroma    .     .  p.  Qi 

disease    called    Rhinoscleroma J 

.    .    .    With  this  we  shall  study  nasal  folliculitis  .     Folliculitis    .    ...  p.  86 

.    .    .And  fissure  of  the  anterior  angle  of  the-]  ^^      ,    ^  _ 

,  .,                                                              t,         /  ^  Nasal  fissure  .    .    .  p.  87 

nostril J  ^ 

.    .    .  Also    furuncle Furuncle   .    .    ...  p.  87 

(3)  The  third  chapter  will  deal  ivith  tuberculous^. 

lupus  of  nasal  origin  and  its  development J  ^      .  .    .   .  P-    / 

(4)  Finally  the  nostrils  form  one  of  the  seats^ 

of  election  of  syphilitic  lesions,  tertiary  or  hercdi-hNasal  Syphilis  .  .    .   p.  89 

tary,  zvhich  we  must  study  briefly J 

/  shall  say  a  fczv  zvords  concerning   the  exotic^ 
disease   called   Rhinoscleroma J  '  * 

STREPTOCOCCIC  NASAL  IMPETIGO. 

Nasal  impetigo  consists  in  yellow  crusts  obstructing  the  nasal 
cavity,  and  a  continual  serous  discharge  from  the  nose  trickling 
down  the  upper  lip.  It  arises  with  impetigo  of  the  face  and  per- 
sists after  it.  At  night  the  nasal  mucous  collects  in  yellow  crusts 
and  obstructs  the  nose.  In  the  morning  the  child  wipes  off  the 
crusts  and  the  discharge  is  reproduced.  Cultures  from  the  crusts 
and  from  the  nasal  discharge  shew  the  presence  of  the  streptococcus. 
There  is  often  perleche  of  the  corners  of  the  lips  and  retro-auricular 
intertrigo  and  fissures  (pp.  74  and  1 1 1 ) .  At  other  times  the  face  bear- 
ill-defined  marks  of  pityriasis  alba  faciei  (p.  10)  of  the  old  writers. 
which  is  a  streptococcic  scurfy  lesion.  Chronic  nasal  impetigo  is 
a  frequent  cause  of  recurrent  acute  impetigo. 


THE    NOSTRILS.  85 

Eventually  the  impetiginous  coryza  determines  in  the  neighbour- 
ing parts,  chronic  oedema  of  the  nose  and  lip,  which  has  been 
described  as  a  characteristic  feature  of  "lymphatism."  This  is  a 
chronic  lymphangitis  connected  with  nasal  impetigo  and  disappears 
gradually  after  removal  of  the  cause. 

Treatment  consists  in  an  intra-nasal  painting  with  a  solution  of 

nitrate  of  silver   (5  per  cent.)   or  ichthyol   (10  per  cent.)  :  and  at 

night  the  application  of  antiseptic  ointments: — 

(i)   Tannin 1 

„  ,         ,  ^    aa  30  centigrammes     aa  gr.  3 

Calomel J 

Vaseline 50  grammes  Bi 

(2)   Resorcine 30  centigrammes        gr.  5 

Oxide  of  Zinc 7  grammes  5ii 

Vaseline 30  grammes  3i 

The  lesion  often  occurs  after  apparent  cure.    Treatment  must 

then  be  repeated. 

ERYSIPELOID     (SO-CALLED     STRUMOUS). 

When  nasal  impetigo  exists  in  a  chronic  state  it  is  not  surprising 
that  recurrent  erysipeloid  of  the  centre  of  the  face  should  be  fre- 
quent. This  is  the  bacteriological  fact  which  clinicians  express  in 
saying  that  it  occurs  especially  "in  pale,  fat,  puffy  children  with  a 
projecting  upper  lip,"  or  "soft-skinned"'  (Critsmaim) .  But  in  chil- 
dren who  continually  absorb  streptococci  and  their  products,  ery- 
sipelas runs  a  special  course.  It  is  characterised  by  "a.  mild  inva- 
sion, little  or  no  fever,  considerable  swelling,  but  slightly  red  and 
painful,  a  slow  and  not  extending  progress  and  frequent  recur- 
rence" (Comby).  In  fact,  erysipelas  presents  all  its  usual  characters 
in  an  attenuated  form.  It  is  a  curious  fact  that  it  is  often  accom- 
panied at  first  by  superficial  phlyctenules,  identical  in  appearance 
and  in  flora  with  the  initial  phlyctenules  of  impetigo,  but  below  these 
the  skin  is  infected  in  its  whole  thickness.  It  is  red,  livid,  and 
swollen,  and  no  longer  an  epidermitis  but  a  streptococcic  dermatitis 

The  evolution  is  that  of  a  benign  erysipelas,  but  the  temperature 
may  exceptionally  rise  above  39°  C.  Treatment  is  the  same  as  for 
erysipelas  of  the  face  (p.  24). 

STAPHYLOCOCCIC    ANTERIOR  RHINITIS. 

This  has  by  itself  very  few  symptoms.  The  subject,  usually  an 
adult,  is  affected  with  "a  cold  in  the  head,"  which  recurs  several 
times  a  year,  and  lasts  almost  constantly. 


86  THE    NOSTRILS. 

When  the  eyehds  are  examined  they  present  chronic  blepharitis 
of  the  ciliary  border,  which  is  red  and  scaly  in  the  morning.  They 
also  bear  an  indefinite  series  of  styes  which  have  lasted  for  years. 
This  pustular  blepharitis  (p.  127)  which  has  the  same  relation  to 
the  eyelids  that  the  chronic  impetigo  of  Bockhart  has  to  the  scalp, 
is  of  stapylococcic  origin.  The  microbial  lachrymal  discharge  infects 
the  nose  with  anterior  rhinitis.  This  rhinitis  in  its  turn  infects 
the  subnasal  region  of  the  moustache  and  reproduces  staphylococcic 
follicular  pustules,  called  sycosis  (p.  149).  The  treatment  of  the 
latter  requires  treatment  of  the  nose,  and  treatment  of  the  nose  that 
of  the  eyelids. 

The  treatment  of  staphylococcic  rhinitis  which  gives  the  best 
results  is  daily  moistening  with  warm  water,  and  the  application 
at  night  of  the  following  ointment. 


Ichthyol     

Resorcine      

Yellow  Oxide  of  Mercury 

Birch    oil 

Vaseline 30  grammes  ji 


-  aa     I  gramme       gr.  16 


If  this  causes  irritation  the  yellow  oxide  may  be  omitted. 


INTRA-NASAL  FOLLICULAR  PUSTULES. 

In  association  with  sycosis  of  the  moustache  which  follows 
staphylococcic  rhinitis,  or  even  with  this  rhinitis  without  sycosis 
of  the  moustache,  there  occurs  a  recurrent  and  chronic  pustula- 
tion  of  the  nostril  at  the  base  of  the  nasal  hairs.  This  pustula- 
tion  may  require  the  same  treatment  as  sycosis  of  the  moustache 
— epilation  or  X-rays,  (p.  149). 

One  should  always  begin  by  lavage  of  the  nose  for  several 
weeks  with  saline  solution,  and  by  local  applications,  such  as 
sulphur  lotion: — 

Precipitated    sulphur 10  grammes      5i 

Alcohol    (90   per  cent) 20  grammes     3ii 

Rose     water ....   70  grammes      3i 

Or  yellow  oxide  of  Mercury  ointment  (i  per  cent.)  which  often 
gives  satisfactory  results. 


THE    NOSTRILS.  87 

NASAL  FURUNCLE. 

Sometimes  at  the  entrance  of  the  nostril  a  true  furuncle  de- 
velops, which  proceeds  from  a  follicular  pustule  of  the  preceding 
type.  The  mechanism  of  its  production  will  be  explained  later 
on  (p  183).  This  furuncle  is  very  painful  because  it  is  developed 
in  the  dense  tissue  in  the  dermis.  It  is  very  unsigthly  on  account 
of  the  surrounding  oedema  which  it  provokes,  and  it  ends  in  the 
formation  of  a  sequestrum  or  core  after  the  manner  of  a  true 
furuncle.  It  leaves  behind  it  a  local  oedema  which  persists  for 
a  long  time.  The  treatment  of  this  furuncle  does  not  differ  from 
that  of  feruncle  in  general  (p.  185). 

NASAL    FISSURE. 

In  the  symptomatic  syndrome  which  the  three  preceding  arti- 
cles present,  there  often  occurs  a  fissure  of  the  anterior  nasal 
commissure,  of  long  duration  and  recurring  after  cure.  By  press- 
ing on  the  nose  it  is  caused  to  open  and  gape.  It  is  often  of  very 
small  dimensions  and  without  apparent  proportion  to  the  symp- 
toms by  which  it  is  accompanied,  for  it  is  sensitive  to  the  least 
touch.  It  may  follow,  precede  or  accompany  intra-nasal  follicular 
pustulation.  The  application  by  a  brush  of  a  drop  of  Friar's  bal- 
sam ;  repeated  painting  with  nitrate  of  silver  (i  in  15) ;  ointments 
of  oil  of  cade,  or  the  pure  oil,  in  these  cases  give  good  results, 
provided  the  application  is  continued  long  enough. 

Cauterisation  by  pencils  of  nitrate  of  silver  followed  by  metal- 
lic zinc  should  be  used  when  the  first  measures  fail.  This  should 
be  repeated  every  week  till  healed. 

TUBERCULOUS  LUPUS. 

The  centre  of  the  face  is  the  most  common  situation  of  tuber- 
culous lupus :  Nine  times  out  of  ten  it  is  of  nasal  origin  and  com- 
mences at  the  orifice  of  the  nose.  The  researches  of  Straus  have 
shevv-n  the  presence  of  the  tubercle  bacillus  on  the  mucosa  of  the 
nose  in  a  healthy  subject.  When  inspired  with  the  air  it  is  ar- 
rested by  the  nasal  hairs  and  this  is  no  doubt  the  origin  of  a 
certain  number  of  cases  of  lupus,  which  are  so  common  in  this 
situation. 


^  THE    NOSTRILS. 

Lupus  begins  usually  on  the  border  of  the  nostril  by  one  or  two- 
slightly  raised  tubercles,  of  a  rose  colour,  disappearing  by  pres- 


Figr.  34.     Mutilating  lupus  of  the  nose  and  lips,  causing  nasal  atresia. 
(Le  Dentu's  patient.     St.   Louis  Hosp.   Museum,   No.    5V0.) 


sure  excepting  a  yellowish  red  spot  in  the  centre.  These  tubercles 
enlarge  and  multiply,  and  the  lupus  patch  invades  the  side  of  the 
nose  or  the  lobule. 


THE    NOSTRILS.  85 

Here  as  elsewhere  lupus  undergoes  one  or  other  of  the  well- 
known  evolutions  which  we  have  enumerated  (p.  20).  The  evo- 
lution may  be  progressive,  slow  and  fibrous ;  or  rapid  with  soft 
cutaneous  tubercles,  leaving  a  soft  raised  patch  which  may  be- 
come fungous  and  ulcerated;  or  mutilating.  Lupus  of  the  nose 
is  the  most  dangerous  of  all,  owing  to  its  peculiar  evolution  and 
situation  and  the  difficulty  in  applying  the  only  really  curative 
treatment,  which  is  phototherapy. 

The  law  which  should  regulate  the  therapeutics  of  lupus  is 
more  true  for  this  form  of  lupus  than  for  any  other.  The  diag- 
nosis must  be  made  early  and  the  patient  must  be  induced  to  un- 
dergo treatment  without  delay.  The  difficulties  of  treatment  in- 
crease with  the  size  and  age  of  the  lesions  (see  page  21  for  photo- 
therapy). 

We  may,  after  the  manner  of  Finsen,  combine  phototherapy 
with  scarification  of  the  nodules  and  cauterisation  of  the  ulcers 
with  permanganate  of  potash,  i  per  cent.,  10  per  cent.,  or  even 
pure. 

Treatment  of  the  interior  of  the  nostrils,  which  is  nearly  always 
inaccessible  to  phototherapy,  requires  repeated  applications  of 
the  galvano-cautery,  and  cauterisation  by  pencils  of  nitrate  of 
silver  and  metallic  zinc  alternately. 

But  we  should  bear  in  mind  that  phototherapy  is  necessary 
and  the  patient  should  be  urged  as  much  as  possible  to  undergo 
this  treatment,  which  is  the  only  one  absolutely  effective  when 
well  performed.  It  is  a  disgrace  to  therapeutics  for  cases  analo- 
gous to  that  represented  in  Fig.  34  to  be  seen;  cases  where  the 
cicatrix  is  made  so  slowly  and  is  so  deformed  and  atresic,  that 
the  face  is  rendered  monstrous.  Such  misfortunes  should  not 
occur  now  that  we  have  the  means  to  avoid  them. 


SYPHILIS.    PERFORATION  OF  THE  SEPTUM.    SADDLE  NOSE. 

Tertiary  lesions  of  the  nostrils  are  frequent,  especially  bony 
lesions.  The  skeleton  of  the  nose  is  one  of  the  seats  of  election 
of  advanced  syphilis.  These  lesions  are  insidious ;  they  arise 
and  develop  without  pain.  A  chronic  coryza  may  occur,  in  the 
course  of  which  the  patient  wipes  pus  from  the  nose  and  even- 
tually finds  bony  fragments  in  the  pus.     Sometimes  the  lesion 


90 


THE    NOSTRILS. 


is  situated  on  the  septum  and  causes  perforation.  Nearly  all 
perforations  of  the  septum  belong  to  tertiary  or  hereditary  syph- 
ilis. Sometimes  the  lesions  occur  in  the  nasal  bones.  In  these 
cases  there  is  a  chronic  purulent  coryza,  frequent  elimination  of 
bony  fragments  and  foetid  breath.  Eventually  the  nose  falls  in, 
the  back  of  the  nose  preserves  its  form,  but  is  sunk  in  an  arch 


Fig.    33.      Tertiary    syphilis    of    tlie    nasal    b'Tits.        -.SaddlL     iiuae." 
{Sabouraud's  patient.      Photo  by  Noire.) 


formed  by  the  two  nasal  processes  of  the  superior  maxilla,  which 
remain  intact.  The  nose,  driven  in  on  itself,  or  "saddle  nose," 
is  characteristic  of  tertiary  syphilis,  and  allows  a  retrospective 
diagnosis,  because  the  lesion,  when  once  formed,  remains  in 
spite  of  all  treatment. 


THE    NOSTRILS.  91 

Treatment,  which  must  be  commenced  as  soon  as  possible,  is 
the  same  as  for  syphilis  in  all  situations.  It  should  be  rapid, 
because  these   lesions   progress   quickly  and  are   irreparable. 


HEREDITARY  SYPHILIS  OF  THE  NOSE. 

Late  heriditary  syphilis  may  manifest  itself  in  the  nose  and 
nostrils  by  ulcerative  lesions  which  resemble  the  type  of  ulcera- 
tive lupus  of  the  same  region  so  closely  as  to  be  often  confounded 
with  it. 

It  consists  of  an  ulcerative  gumma  of  a  torpid  appearance, 
developing  without  functional  symptoms  and  especially  without 
pain,  slowly  and  progressively,  and  terminating  by  converting 
the  centre  of  the  face  into  a  vast  ulcer,  destroying  the  lower 
part  of  the  septum,  the  upper  part  of  the  lip  and  sometimes  the 
lower  part  of  the  nose,  the  bone  itself  being  destroyed. 

These  mutilating  lesions,  which  are  fortunately  rare,  occur  at 
the  same  age  as  lupus,  from  12  to  15  years,  which  adds  to  the 
difficulty  of  diagnosis.  The  stigmata  of  heredo-syphilis  affecting 
the  teeth,  eye,  ear,  tibia,  etc.,  should  be  carefully  looked  for.  The 
lesion  is  gummatous  and  soon  ulcerates.  Lupus  rarely  follows 
this  evolution,  but  is  hypertrophic  before  becoming  ulcerated,  as 
a  rule.  Syphilis  destroys,  perforates  and  necroses  the  bones ; 
tuberculosis  only  attacks  the  surface  and  corrodes  them  slowly, 
without  perforating  and  without  producing  a  true  sequestrum. 

Treatment  is  often  the  only  proof  of  the  syphilitic  nature  of  the 
disease.  However,  hereditary  syphilis  may  resist  for  a  long  time 
the  best  form  of  mixed  treatment,  and  many  cases  of  tuberculous 
lupus  receive  a  certain  amount  of  benefit  by  mercurial  treatment 
in  the  early  stages. 

RHINOSCLEROMA. 

Rhinoscleroma  is  a  disease  of  equinoxial  America,  characterised 
by  a  naso-pharyngeal  catarrh  and  a  new  growth  of  the  same 
region.  This  neoplasm  is  relatively  benign,  but  may  invade  the 
whole  throat,  the  fauces  and  soft  palate,  and  end  fatally. 

It  generally  arises  from  the  nasal  orifice  and  the  upper  lip  in 
the  form  of  a  tumour  surrounding  the  orifice  of  the  nose  and 


92 


THE   NOSTRILS. 


forming  part  of  the  lip.  The  tumour  is  of  a  violet  colour,  very 
regular  in  form  and  of  hard  consistence ;  in  our  country  its  evo- 
lution is  often  arrested.  This  disease  appears  due  to  a  bacillus 
very  similar  if  not  identical  with  the  pneumo-bacillus  of  Fried- 
lander,  and  is  found  in  the  large  phagocyte  cells  characteristic 
of  the  disease.  All  the  forms  of  treatment  recommended  for 
lupus  have  been  tried  in  this  disease.  In  early  cases,  opening  the 
nose  and  scraping  may  be  tried.  When  operative  measures  would 
necessarily  be  incomplete,  palliative  treatment  only  is  available, 
by  mechanical  dilatation  of  the  nasal  fossae. 


THE   NOSE    AND    CHEEKS. 


-  Seborrhcea  .    .   .   ,  p.  94 


The  nose,  with  the  centre  of  the  face,  is  one  of  the  most  in- 
teresting dermatological  regions. 

//  is  here  that  seborrhoea  and  the  sehorrhoeic' 
or  super-seborrhoeic  processes  begin.  It  is  on  the 
sides  and  lobule  of  the  nose  that  dilatation  of  the 
sebaceous  pores  commences  in  trtie  seborrhoea  .   . 

It  is  here  also  that  the  complications  are  seen;^ 
acne  comedo,  with  its  black  spots jAcne  comedo  .    . 

.    .    .  Acne    polymorphe,    zvith    its    various    elc-'\ 
mcnts— redness,  induration,  pustules,  cysts,  etc.   .    J  ^cne  po'ymorphe 

.    .    .   And  even  most  frequently  acne  necrotica,] 

!- Acne 


P-95 


P-9S 


necrotica 


p.  96 


p.  98 

p.  98 
p.  99 


■which    leaves   varioliform    cicatrices  .... 

It  is  in  the  naso-senial  fold  that  one  of  the  most^  -r,-.     •     ■          r  , 

^,.     ,f           f       ,       J             r             ,,     Pityriasis      of  the 

common    complications    of   seborrhoea    of   smooth  V                    ■  ,  r  ,  ■, 

'.,.••,,,,,                                     naso-genial  fold  p.  97 
regions  occurs — pityriasis  zuith  fatty  squames  .    .    .  j 

The  nose  is  a  seat  of  predilection  for  vaso-motor\Yaso-motor     disor- 
■disorders   and   chilblains J      ders.     Chilblain 

The  nose  is  a  seat  of  predilection  for  vaso-motor-\  Vaso-motor     disor 
■disorders  or  chilblains J      ders,  chilblains 

Here  is  observed  erythema  pernio,  zvhich  appears') 
to  cover  the  nose  zvith  a  placard  of  chilblain  .    .    J  Erythema    pernio  , 

The  bridge  and  lateral  faces  of  the  nose  are  the]  -,  , 

,       ,  ,  '  ,,         ,  /T7  Lupus    erythemato- 

most  common  scats  of  lupus  erythematosus   {l/es-h 

pcrtilio) J 

One  observes  on  the  nose  not  only  tuberculous 
erythemas,  but  true  tuberculosis,  for  the  lobule 
and  alae  of  the  nose  are  often  affected  and  de- 
stroyed by  tuberculous  lupus  arising  from  the  nasal 
orifice - 

The  nose  may  be  the  scat  of  a  zvhole  group  ofi  Tertiary 
tertiary  acniform  syphilidcs J      lides  . 

Lastly,  tozvards  the  50//?  year  a  group  of  passive 
congestive  lesions  combine  zvith  seborrhoea  to 
create  neiv  types  in  the  centre  of  the  face.  Varices 
of  the  nose,  zvhich  form  on  the  alae  and  lobule, 
purple  serpentine  lines;  or  that  passive  congestion 
zvhich  causes  the  large  red  noses  attributed  specially 
to  drinkers 

.    .    .  And  this  passive  congestion  is  accompanied 
by  all  the  types  of  acne,  developing  in  the  midst  of  V 
a  hypertrophic  and  even  benign  neoplastic  process] 

Other  neoplastic  papillomatous  processes  may  be']  „     ., 
^     ,.       J  •     .7        77  /      -jji  !- Senile     Warts 

superposed  t>i  the  seborrhoea  of  middle  age  .    .    .    .j 


sus p.  100 


-Tuberculous  lupus  p.  loo 


Syphi- 


p.  lor 


Congestive  Acne 
of  middle  age, 
Acne    rosacea 


Acne    hypertrophi- 
ca  Rhinophyma  . 


p.  102 


p.  103 


p.  104 


Finally,  I  sliall  terminate  this  chapter  by  saying 
a  few  words  concerning  divers  clinical  facts  of 
less  importance  or  of  less  frequency,  which  may  be 
observed  in  the  same  region 


94  THE   NOSE   AND   CHEEKS. 

.   .   .  Of  which  some  are  less  benign,  such  as] 
epithelioma,  which  occurs  with  a  relative  benignity,  I  Epithelioma   ...  p.  105 

at  least  at  first I 

Hypertrichosis       .  p.  106 

Naevi p.  106 

Xanthelasma  ...  p.  107 
Molluscum       con- 
.     tagiosum  ....  p.  107 
Adenoma      sebac- 
eum     p.  107 

Darier's  disease    .    p.  107 
Glanders    .    ...  p.  io8- 

SEBORRHOEA. 

Everyone  knows  this  condition  of  the  skin,  which  is  so  marked 
in  certain  persons,  in  whom  the  skin  becomes  coarse  and  covered 
with  the  visible  openings  of  the  sebaceous  glands.  This  is  the 
elementary  lesion  of  Seborrhoea  (p.  13).  Seborrhoea  begins  in 
the  naso-genial  fold  and  on  the  nose,  a  little  before  the  age  of 
puberty.  It  becomes  pronounced  and  extends  beyond  its  first 
limits  during  youth. 

This  condition  occurs  in  all  degrees,  the  less  marked  cases  being 
hardly  recognisable;  in  the  most  marked  the  nose  is  covered 
with  an  oily  coating  arising  from  the  sebaceous  glands.  The  char- 
acteristic of  this  condition,  which  presents  no  subjective  sign, 
is  the  excessive  formation  of  cutaneous  fat  and  its  accumulation 
in  the  sebaceous  canals. 

This  fat  can  be  expressed  by  the  fingers  from  each  sebaceous 
orifice  like  a  worm.  This  fatty  cylinder,  the  origin  of  the  comedo, 
is  a  microbacillary  colony,  characteristic  of  the  seborrhoeic  state 
which  I  have  just  described  (for  methods  of  examination  and 
culture  see  p.  13). 

In  severe  forms  the  abundance  of  secretion  requires  treatment. 
In  less  marked  forms,  quasi-normal,  most  subjects  are  not  treated. 

The  chief  agent  is  sulphur,  which  may  be  used  in  the  form  of 
powder,  lotion  or  ointment.  In  spite  of  the  statements  of  many 
writers,  experience  shows  that  ointments  are  as  useful  as  lotions. 

POWDER. 

Precipitated    Sulphur 

Oxide  of  Zinc ^  equal   parts 

Talc 


THE    NOSE    AND    CHEEKS.  9S 

This  powder  is  applied  at  night  with  a  powder  puff  and  washed 
off  in  the  morning.  A  little  vaseline  is  applied  to  protect  the 
eyelids. 

LOTION. 

Precipitated    Sulphur    .    .      1  1  _. 

Alcohol    (90  per   cent.)   .     J     ^^       '5  grammes|aa    3j 
Distilled   water 100  grammes  5j 


I  gramme        gr.  16 


OINTMENT. 

Precipitated    Sulphur    .    . 

Resorcine 

Ichthyol     

Vaseline 30  grammes  3j 

The  action  of  the  sulphur  may  be  increased  by  mordants ;  pre- 
liminary soaping,  salicylic  acid,  etc. 

In  severe  cases  the  action  of  sulphur  may  be  combined  with 
soft  soap,  according  to  the  tolerance  of  the  patient's  skin  ;  or 
sulphide  of  carbon  saturated  with  sulphur  may  be  applied  on  ab- 
sorbent wool  (this  is  very  inflammable). 

ACNE  COMEDO. 

Acne  comedo  is  only  a  variety  of  seborrhoea.  In  seborrhoea 
each  sebaceous  gland  discharges  its  contents  on  the  skin  con- 
tinually; in  acne  comedo  the  fatty  cylinder  in  the  sebaceous 
canal  develops  to  the  point  of  obstructing  the  sebaceous  pores. 
Its  summit  becomes  black  and  the  seborrhoeic  cylinder  becomes 
an  ampulla,  the  comedo,  which  appears  as  a  black  spot  in  the  se- 
baceous orifice,  and  can  be  expressed  by  the  fingers.  It  forms 
a  large  microbacillary  colony. 

The  comedo  may  be  treated  by  extraction  by  a  watch  key, 
or  by  instruments  based  on  the  same  principle,  comedo  ex- 
tractors. This  is  combined  with  the  topical  applications  for 
seborrhoea.  Seborrhoea  always  co-exists  with  comedo,  which 
is  only  a  clinical  accessory. 

ACNE    POLYMORPHE. 

At  the  period  of  youth  polymorphous  acne  of  the  nose  and 
centre  of  the  face  does  not  differ  from  that  of  the  face  in 
general   (p.   15).     It  is  only  an  epiphenomenon,  and  its  different 


S6 


THE    NOSE    AND    CHEEKS. 


modifications  have  a  frequent  predilection  for  the  sides  of  the 
nose  and  the  naso-genial  furrow.  The  treatment  is  that  of 
polymorphous  acne  in  general. 

ACNE   NECROTICA. 


Acne  necrotica  is  a  suppurating  acne  with  discoid  crusts  im- 
bedded in  the  skin,  leaving  a  varioliform  depression  when  they 

fall.     In   the   light  of   recent 
^7^^  researches,  it  is  a  hybrid  of 

pustular    folliculitis    and    se- 
?*i*X  X  borrhoea;      an      impetigo      of 

\  Bockhart  situated  on  the  se- 
borrhoeic  microbacillary  cyl- 
inder. 

The  disease  has  three  seats 

of      election ;      the      forehead 

(acne  frontalis  of  Hcbra)  ;  the 

/      middle      facial      and      middle 

]%^^^^^^-  /  thoracic     regions.       One     of 

these  localisations  may  occur 
,  alone. 

%  ^fc;  ,.  /  On   the   nose    (Fig.   36)    it 

\*^fe^  consists  of  a  crop  of  lesions 

"'"■**'  /  of  different  sizes,  forming  a 

'"'  "  discoid  crust  in  the  epidermis, 

which    is    not    detached    for 

FJg.  30.     Cicatrices    of   necrotic    acne    of    the      SOmC      time.         Thc       Varioloid 
face.      (Besnier's    patient.     St.    Louis  ...  ^  , 

Hosp.  Museum.  No.  498.)  cicatnx     IS     permanent     and 

arises   from   necrosis,   always 

produced   by   impetigo    of   Bockhart,    but   more   marked    in   acne 

necrotica. 

Acne  necrotica  occurs  at  two  periods ;  in  the  young  adult,  when 

it  is  amenable  to  treatment  and  may  not  recur ;  about  the  50th 

year,  when  it  is  more  severe  and  extensive,  see  (Scalp  p.  235). 

Even  in  these  cases  the  actual  eruption  is  easily  curable  by 

preparations  of  mercury  and  sulphur: — 

Cinnabar 1  .  ^■ 

„..,.,    c  1  1  r  ^^    ^  gramme      gr.  16 

Precipitated    Sulphur J 

Vaseline      30  grammes  3j 


THE    NOSE   AND    CHEEKS.  97 

But  local  treatment  does  not  prevent  recurrence.  This  clinical 

fact  applies   to  other  localisations  of  the  disease  and  will  be 
referred  to  again  (p.  123  &  235). 


NASO-GENIAL   PITYRIASIS. 

When  studying  diseases  of  the  scalp  (p.  207)  we  shall  see 
that  pityriasis  simplex  capitis  is  a  morbi'd  entity  of  mycotic  origin 
like  pityriasis  versicolor,  and  that  its  dry  scales  may  assume  a 
fatty  appearance  by  secondary  infection  with  a  coccus  forming 
a  grey  culture  (p.  201),  This  symbiosis  gives  the  disease  a  ten- 
dency to  diffusion.  It  is  generally  in  this  form  of  steatoid 
pityriasis  that  pityriasis  occurs  apart  from  the  scalp. 

The  centre  of  the  face  is  one  of  its  seats  of  election,  chiefly 
the  naso-genial  furrow ;  also  the  head  and  eyebrows.  It  occurs 
in  the  form  of  small  pale  yellow  scales  which  accumulate  in 
the  naso-genial  furrow.  These  form  again  a  few  hours  after 
removal.  This  formation  is  accompanied  by  local  itching  and 
smarting.  W'ith  a  lens  the  skin  appears  moist,  and  gives  the 
same  sensation  to  the  fingers.  The  scales  appear  fatty  like  wax 
and  leave  a  mark  on  blotting  paper,  similar  to  that  left  by 
impetigo. 

The  treatment  is  entirely  external  and  includes  the  use  of  tar 
and  sulphur,  associated  when  the  skin  will  bear  it. 

Precipitated    Sulphur i  gramme  gr.  20 

Oil  of    Cade 5           "  5  ii  ss 

Lanoline 10          "  5v 

Vaseline      15           "  3} 

When  the  skin  is  irritable  or  the  eruption  very  extensive  the 
following  may  be  applied  at  night  and  washed  off  in  the  raorinng 
with  tar  soap  : — 

Oil  of   Cade 5  grammes  5  ii  ss 

Oil  of  Birch | 

Resorcine faa     i  gramme  gr.  20 

Ichthyol      j 

Lanoline 10  grammes  3v 

Vaseline      15  "  3i 

This  pityriasis  is  the  type  of  a  disease  essentially  super-se- 
borrhoeic  in  its  localisations  on  smooth  regions.  It  is  recur- 
rent in  seborrhoea  because  the  latter  is  permanent. 

7 


98  THE    NOSE    AND    CHEEKS. 

VASO-MOTOR    AND    VASCULAR    DISORDERS. 

The  older  observers  distinguished  two  types  of  vaso-motor  and 
vascular  affections  of  the  nose :  an  active  type  occurring  in  young 
people  and  connected  with  other  manifestations  formerly 
claimed  as  lymphatic;  a.  passive  type  occurring  in  middle  age  and 
connected  with  manifestations  which  are  still  known  as  arthritic. 
Until  these  general  morbid  conditions  (lymphatism,  arthritism, 
etc.)  are  better  defined  it  is  unwise  to  accept  the  idea  as  valid, 
or  its  existence  as  being  demonstrated.  This  classification  should 
only  be  regarded  as  a  simple  mnemonic  measure. 

To  the  first  type  belong  chilblains ;  lupus  pernio ;  lupus  erythe- 
matosus, mobile  or  fixed.  Some  would  even  include  tuberculous 
lupus  in  this  group. 

To  the  second  type  belong  varices  of  the  nose;  hypertrophic 
acne  with  congestion  ;  pustular  and  cystic  lesions  and  deformities, 
the  combination  of  which  creates  rhinophyma ;  complications 
which  may  be  superposed  in  senile  skins — warts,  concrete  se- 
borrhoea  and  epithelioma. 


CHILBLAIN  OF  THE  NOSE. 

Chilblain  of  the  nose  may  occur  in  children  with  chilblains 
in  other  situations,  but  also  in  adults  by  itself.  It  then  has 
special  characters. 

The  nose  is  cold ;  the  lobule  slightly  enlarged,  rounded  and  of 
a  purple  colour  which  disappears  on  pressure.  At  night  there 
may  be  congestion  with  itching,  but  more  often  these  are  absent. 
Chilblain  of  the  nose  is  first  observed  in  the  winter,  but  it  may 
last  through  the  summer  and  reappear  in  the  autumn.  Usually  it 
co-exists  with  chilblain  of  the  ears.  This  condition  is  not  much 
affected  by  the  mode  of  life,  diet,  or  therapeutics,  and  is  espe- 
cially distressing  when  it  occurs  in  3^oung  women. 

In  some  cases  it  may  excite  nasal  troubles  such  as  adenoiditis, 
rhinitis,  deviation  of  the  septum,  polypi,  etc.,  by  reflex  action. 
In  such  cases  therapeutic  intervention  is  indicated.  High  and 
ti|^ht   collars   which   impede   the  venous   circulation   should   be 


THE    NOSE    AND    CHEEKS.  99 

avoided ;  the  diet  should  be  regulated  to  avoid  digestive  troubles, 
which  cause  reflex  congestion  of  the  face.  Locally,  glycerole  of 
starch  with  resorcine  (i  per  cent.)  or  zinc  ointment  may  be 
tried.    In  the  best  cases  these  measures  are  only  mediocre. 

I  should  have  much  more  faith  in  treatment  similar  to  that  for 
lupus  erythematosus,  by  repeated  applications  of  the  X-rays  in 
high  doses,  or  phototherapy. 


ERYTHEMA  OR  LUPUS  PERNIO. 

The  term  lupus  is  bad,  for  the  tuberculous  origin  of  this  lesion 
is  far  from  being  proved.  The  action  of  cold  in  its  genesis 
is  only  that  of  a  determining  cause  which  only  produces  this  re- 
sult in  very  few  subjects.  It  resembles  a  chilblain  of  the  nose 
with  extension  to  both  cheeks.  The  lesion  is  roughly  sym- 
metrical, of  a  dififuse  red  colour  with  marbling  of  the  skin,  and 
oedematous  in  all  parts.  It  is  transient  but  liable  to  recurrence, 
and  may  remain  permanent  with  temporary  exacerbations,  re- 
sembling lupus  only  in  its  situation  and  form,  which  are  those 
of  lupus  erythematosus.  Concerning  the  genesis  and  treatment 
of  this  afl^ection  all  that  I  have  just  said  with  regard  to  chilblain 
of  the  nose  applies  to  erythema  pernio. 


MOBILE  LUPUS  ERYTHEMATOSUS. 

Between  chilblain  of  the  nose  and  lupus  pernio  on  the  one 
hand  and  true  lupus  erythematosus  on  the  other,  and  also  acute 
infectious  patchy  erythemas  of  the  type  of  certain  polymorphous 
erythemas,  there  exists  a  series  of  clinical  cases  still  unclassi- 
fied. These  are  recurrent  at  certain  places,  which  suggests  an 
infectious  origin  causing  eruptive  patches  by  toxic  discharges. 
These  unclassified  cases,  which  perhaps  belong  to  different 
categories,  have  been  provisionally  united  under  the  name  of 
mobile  lupus  erythematosus.  The  boundary  of  lupus  erythe- 
matosus is  sufificienth'  large  and  ill  defined  to  include  this  type 
by  the  side  of  the  others,  in  spite  of  the  great  clinical  differences. 


loo  THE  NOSE  AND  CHEEKS. 

TRUE  LUPUS  ERYTHEMATOSUS. 

The  nose  is  one  of  the  seats  of  election  of  fixed  or  true  lupus 
erythematosus  in  its  usual  form.     It  is  rarely  confined  to  the 

nose  and  there  are  usually 
patches  of  similar  character 
on  the  face  (Fig.  8). 

The  patches  are  of  irregular 
outline ;  symmetrical  or  not 
with  the  axial  line  of  the  nose ; 
depressed  and  cicatricial  in 
the  centre  and  surrounded 
with  a  red  border,  slightly 
raised  and  covered  with  ad- 
herent scales.  All  these 
lesions  are  obvious  to  the 
touch.  They  are  chronic 
patches  of  indefinite  duration, 
developing  slowly  by  periph- 
eral extension  and  receding 
sometimes  at  one  place  while 
advancing  at  others.  Spon- 
taneous or  therapeutic  cure 
replaces  the  lesion  by  a  white, 
depressed,  cicatricial,  indeli- 
^^^iT.'f'^''  ble,  sometimes  marbled  patch 

o.    1014.)  '  ^ 

(Fig.  37)- 

I  have  already  spoken  of  lupus  erythematosus  of  the  face 
(p.  i8)  and  I  shall  refer  to  that  of  the  ear  later  on  (p.  112). 
In  all  situations  it  preserves  the  same  characters.  Treatment 
by  radiotherapy  is  daily  becoming  more  exclusive.  The  sittings, 
of  5  or  6  units  H,  should  be  repeated  every  three  weeks. 
Radiodermatitis  is  only  of  moderate  severity  in  these  cases, 
and  a  cure  is  obtained  more  quickly  and  with  a  better  cicatrix 
than  by  any  other  method. 

TUBERCULOUS   LUPUS. 

Tuberculous  lupus  of  the  nose  is  very  common.  It  is  usually 
secondary  to  lupus  of  the  nasal  orifice  (p.  87).  It  has  a  great 
tendency  to  develop  on  the  lobule  or  sides  of  the  nose  (Fig.  38), 
and  gradually  invades  the  upper  lip.    It  most  often  assumes  the 


Fig.  37.     Lupus     Erythematosus, 
patient.     St.    Louis   Hosp.    Mus.,    No 


THE   NOSE   AND   CHEEKS. 


lOI 


/ 


Fig.  38.     Vegetating     lupus     of     the     nose.      (Besnier's 
patient.     St.    Louis    Hosp.    Museum,    No.    522.) 


hypertrophic  fungating  form  and  proceeds  to  destructive  ulcera- 
_  tion.  Thi^  process 

after  some  years 
causes  disappear- 
ance of  the  soft 
parts  of  the  nose 
and,  even  when 
healed,  leaves 
horrible  scars 
which  contract  or 
entirely  close  the 
nostrils  (Fig.  34). 
I  have  already 
mentioned  the 
treatment  of 
lupus  (p.  21)  and 
described  how  all 
the  older  methods  should  be  used  to  assist  the  only  truly  cura- 
tive treatment  by  phototherapy  (p.  21). 

TERTIARY  ACNIFORM  SYPHILIDES  AND  GUMMATA  OF  THE 

SKIN. 
There  are  too  common  syphilitic   lesions  of  the  nose  which 

have  also  a  preference  for  the  naso-genial  fold,  the  alse  of  the 

nose  and  cheeks.  The  first  forms 
a  red,  irregular  placard  on  which 
occur  adherent  scabs  covering 
sharply  cut,  slightly  discharging 
ulcers,  which  are  only  seen  on  re- 
moval of  the  scabs.  This  lesion 
occurs  in  old  cases  of  syphilis  of 
10  to  15  years'  duration,  or  more. 

The  second  form  is  composed 
of  the  same  elements,  but  dissemi- 
nated (Fig.  39).  This  lesion  is 
frequently  mistaken  for  necrotic 
acne.  All  local  treatment  is  in- 
effective, but  the  lesion  yields  to 

rig.  89.    papuio-uicerative    acniform      mixed  internal  treatment  in  a  few 

syphilide.      (Jeanselme's    patient.  , 

Photo    by    Noirf.)  WCCKS. 


102 


THE  NOSE   AND    CHEEKS. 


PASSIVE    CONGESTION    AND    VARICES. 


Towards  the  50th  year,  in  patients  affected  with  heart  disease 
or  renal  affections,  or  in  the  absence  of  these,  acne  hypertrophica 

and  varicose  congestion 
of  the  nose  become  ac- 
centuated. The  nose  is 
swollen,  cold  to  the 
touch,  and  of  a  purple 
colour. 

The  coarse  skin  is 
riddled  with  the  visible 
orifices  of  distended 
sebaceous  pores.  On  the 
deep  red  uniform  base 
of  the  skin  are  seen  vari- 
cose veins  of  various 
sizes  and  forms.  Some 
follow  the  nose  longi- 
tudinally ;  others  are  in 
parallel  arcades,  cover- 
ing the  sides  of  the 
nose  and  anastomosing 
with  each  other. 

This     condition,     the 
causes  of  which  are  un- 
known,    but     which     is 
often    consanguineous 
and    hereditary,    is    permanent    and    progressive.      The    chronic 
gastric  disorders  which  occur  in  drinkers  may  exaggerate  it,  but 
are  not  the  cause. 

Treatment  is  entirely  surgical  and  consists  in  puncture  of 
all  the  visible  veins  with  a  fine  galvano-cautery.  After  6  or  8 
operations  of  this  kind,  the  lesions  subside.  The  congested 
state  of  the  skin  may  be  remedied  by  quadrilateral  linear  scari- 
fications continued  at  long  intervals  of  18  days  for  15  to  20  ap- 
plications. 

The  action  of  radiotherapy  on  acne,  which  is  admitted  in 
Germany  and  America,  is  at  present  less  known  in  France  and 


Fig.  40.     Acne     rosacea     and     polymorphous     acne. 

(Besnler's    patient.     St.     Louis    Hosp.    Museum, 

No.    583.) 


THE  NOSE  AND  CHEEKS. 


103 


less  often  practised.     In  all  severe  cases  it  should  be  tried,  espe- 
cially if  the  patient  objects  to  repeated  surgical  interference. 

ACNE   HYPERTROPHICA.    RHINOPHYMA. 


Hypertrophic  acne  begins  at  the  age  of  20  and  attains  its 
maximum  at  60  or  70  years.    At  twenty  the  subject  is  congested 

and   flushes   easily.     The  skin 
'^   '   ^^  of  the  face  is  too  red,  and  al- 

ready shows  enlarged  se- 
baceous pores  and  resembles 
the  skin  of  an  orange.  With 
advancing  age  this  condition  is 
^^^^^      -^^^  increased  and  the  skin  becomes 

i  ij^^^^Mr'  ^^^H^/^'i  j  thickened,  rough  and  irregular 
•  v'BPmi^  *VH9''  ^  ^^^^  more  and  more  coarse. 
\  ■«--■'         '-«»'*'■*  Sometimes  all  the  varieties  of 

t^liWH|H|^j(^^^j|L        %      polymorphous  acne  arise,  espe- 
^^^^^^^^^^^^^^  ^  cially   acne   indurata   and   soft 

masses  of  cystic  acne.  Pres- 
sure between  the  fingers  causes 
white  filaments  to  exude  from 
the  pores.  This  condition  is 
especially  marked  on  the  nose, 
which  loses  its  shape  and  may 
become  increased  in  size  to  a 
remarkable  extent  —  Rhino- 
phyma  (Fig.  41).  Sometimes  the  condition  is  confined  to  the 
lobule,  sometimes  it  affects  nearly  the  whole  of  the  nose.  It 
is  then  covered  with  protuberances  of  various  degrees  of  de- 
formity and  of  all  colours. 

The  treatment  of  this  affection  is  that  of  congestive  acne  in 
placards,  which  will  be  mentioned  shortly.  Excision  of  all  the 
projections  with  scissors,  or  even  removal  of  the  whole  skin 
has  been  recommended.  The  resulting  cicatrix  is  remarkably 
good,  because  the  operation  cuts  the  glandular  ducts,  which 
form  epithelial  grafts.  In  all  these  affections  treatment  of  the 
subjacent  seborrhoea  and  acne  may  be  combined  with  treatment 
by  the  galvano-cautery  or  scarification.  The  hygiene  of  the  nose 
after  operation  is  the  same  as  for  every  seborrhceic  skin. 


Fig.  41.     Hypertrophic   acne   of  the  nose 

Rhinophyma.        (Lucas      Champion- 

nifere's   patient.     St.    Louis    Hosp. 

Museum,    No.    1780.) 


X04 


THE    NOSE   AND    CHEEKS. 
SENILE   WARTS. 


On  a  nose  affected  with  seborrhoea  and  passive  congestion  at 
middle  age,  senile  warts  and  concrete  seborrhoea  are  of  frequent 
occurrence  (p.  31).  They  are  superposed  on  the  seborrhoea 
of  old  age,  as  pityriasis  is  superposed  on  the  seborrhoea  of 
youth,  and  with  a  peculiar  preference  for  the  same  situation, 
the  naso-genial  furrow.  Sometimes  there  are  yellow,  flat, 
seborrhoeic,  papillomatous  warts,  which 
appear  at  first  to  be  simply  excreta  on  f~ 
the  surface  of  a  badly  washed  skin ; 
sometimes  there  is  concrete  seborrhoea 
which     has     been     described     above 


Fig.  42.     Malignant  epithelioma  of  the  nose.     (Bes- 
nler's  patient.     St.   Louis   Hosp.   Mus..   No.  11!*4.) 


Flff.  43.     Epithelioma     of     the 

nose,     ulcerative.    (Sabour- 

aud's    patient.      Photo 

by    Noire.) 


THE  NOSE  AND  CHEEKS.  lOS 

(p.  31),  consisting  of  small,  hard,  thick  scabs,  like  parchment, 
very  adherent  to  the  skin  and  connected  with  it  by  a  series 
of  villous  prolongations,  penetrating  the  orifices  of  the  sebaceous 
glands. 

The  treatment  of  these  different  senile  superseborrhoeic  pro- 
cesses is  the  same  for  all.  The  skin  should  first  be  treated 
by  the  following  ointment : — 


Chlorate  of  potash 

Precipitated    Sulphur    .... 

Cinnabar    

Resorcine      

Oxide  of  Zinc 5  grammes     3  i  ss 


aa    I  gramme     gr.  16 


Vaseline 30  "  j5 

After  a  time  the  lesions  are  cleansed  and  improved  and  one 
can  observe  what  remains. 

If  there  are  epitheliomatous  pearls,  or  if  small  ulcers 
with  a  hard  border  appear  under  the  scabs  of  the  so-called 
concrete  seborrhoea,  which  are  already  commencing  epithelioma, 
radiotherapy  should  be  practised,  according  to  the  rules  indi- 
cated above  (p.  32). 

The  projecting  papillomata  are  destroyed  by  the  galvano- 
cautery ;  the  flat  warts,  if  they  resist  ointments  containing  sul- 
phur and  chlorate  of  potash,  should  be  destroyed  by  painting 
with  chromic  acid  (10  per  cent). 

EPITHELIOMA. 

Epithelioma  of  the  side  of  the  nose  is  common,  both  in  the 
neoplastic  and  ulcerative  forms.  In  the  neoplastic  form  it  forms 
a  soft  red,  spongy  tumour,  studded  with  necrotic  points,  moist 
and  often  covered  with  scabs  (Fig.  44). 

In  the  other  form  there  is  a  polygonal,  sharply-cut,  red  ulcer, 
varying  in  depth  and  exudation,  and  bordered  with  epithelial 
pearls,  rendering  the  edge  of  the  ulcer  hard  and  glossy.  In 
other  cases  the  ulcer  is  bordered  with  pseudo-pityriasic  circina- 
tions,  which  give  it  an  almost  geometrical  appearance.  Between 
this  circination  and  the  ulcer  is  a  smooth  red  surface  which 
appears  deprived  of  horny  epidermis. 

These  epitheliomas,  in  whatever  form  they  appear,  are  amen- 
able to  radiotherapy,  as  shown  in  Fig.  44. 


io6  THE  NOSE  AND  CHEEKS. 

Five  or  six  applications  are   made  at  intervals  of   i8  days, 


Flgr.  44.     Epithelioma  of  the  nose  cured  by  radiotherapy. 
(Sabouraud's    patient.     Photo     by     Noir§.) 


each  corresponding  to  5  units  of  Hohknecht,  or  the  B  tint  of  the 
radiometer  X  (p.  197). 

HYPERTRICHOSIS. 

Sometimes  towards  the  50th  year  the  nose  becomes  covered 
with  unsightly  hairs.  As  these  hairs  are  usually  large  and  few 
in  number  destruction  by  electrolysis  is  the  method  of  choice 
(P-  143). 

NAEVI. 

Very  often  the  nose,  on  its  lateral  faces,  presents  one  or  two 
stellate  naevi  which  enlarge  with  age.  They  are  usually  easily 
removed  by  the  fine  galvano-cautery,  which  may  require  two 
applications.  When  galvanic  cauterisation  leads  to  cicatrisa- 
tion of  the  central  vessel,  all  the  vascular  rays  arising  from  it 
disappear. 


THE  NOSE  AND  CHEEKS.  Iq7 

XANTHELASMA. 

Xanthelasma  of  the  eyelids  is  sometimes  prolonged  from  the 
glabellum  to  the  root  or  sides  of  the  nose.  It  is  only  an  epi- 
phenomenon  in  the  course  of  Xanthelasma  of  the  eyelids,  (p.  130). 

MOLLUSCUM    CONTAGIOSUM. 

The  small,  soft,  hemispherical  and  umbilicated  tumours  of 
molluscum  contagiosum  often  occur  in  the  naso-genial  furrow, 
or  on  the  alae  or  lobule  of  the  nose.  The  treatment  consists  in 
removal  by  a  curette;  a  painless  operation  which  may,  how- 
ever, require  repetitions  because  the  fine  elements  escape  the 
first  intervention  (Fig.  52  and  p.  129). 

ADENOMA    SEBACEUM. 

Adenoma  sebaceum  is  a  rare  disease,  usually  limited  to  the 
naso-genial  furrow  and  spreading  from  this  as  a  centre-.  It  is 
formed  of  small  irregular  tumours,  sessile  or  semi-pediculated ; 
often  united  in  a  coherent  mass ;  not  umbilicated,  deep  or 
crusted.    They  are  of  a  rose  yellow  colour,  or  more  or  less  red. 

These  lesions  are  of  the  size  of  a  pea  when  situated  centrally, 
smaller  when  they  are  more  excentric.  They  are  bilateral,  with 
a  predominance  on  one  side  and  always  concomitant  with  marked 
seborrhoea. 

They  are  nsevoid  adenomata,  in  which  the  vascular  anomaly 
is  more  frequent  than  the  glandular.  They  occur  at  the  age  of  10 
to  15  years  and  remain  stationary  after  a  period  of  growth. 
They  are  more  common  in  young  girls  and  often  co-exist  with 
other  naevi  of  diverse  forms,  and  with  retarded  intellect. 

They  may  be  destroyed  by  electrolysis,  or  the  curette,  or  by 
the  galvano-cautery.  They  never  recur  even  when  incompletely 
removed. 

Vidal  mentions  their  later  transformation  into  epithelioma. 

DARIER'S   DISEASE. 

I  have  described  this  elsewhere  (p.  25).  I  only  mention 
it  here  because  its  localisation  in  the  naso-genial  fold  may  be 
the  first  and  only  situation  for  some  time.  More  often  all 
localisations  in  the  seborrhcEic  regions  occur  together. 


io8  THE   NOSE   AND    CHEEKS. 


GLANDERS    AND    FARCY. 


I  have  seen  a  case  of  glanders  of  the  nose  in  a  man  of  50. 
The  nose  was  larger  than  normal  and  covered  with  deep  linear 
ulcerations,  resembling  worm  tracks  in  old  wood ;  the  nose  was 
zvorm  eaten  (Besnicr).  There  was  a  specific  coryza  of  both  nos- 
trils discharging  abundant  pus. 

Glanders  was  proved  by  inoculation  of  the  pus  in  the  perito- 
neum of  a  male  guinea  pig,  which  showed  specific  orchitis  in 
five  days.  The  pus  from  the  orchitis,  sown  on  potato,  produced 
cultures  in  drops,  of  a  characteristic  chocolate  colour. 

The  prognosis  of  this  disease  is  fatal,  and  the  course  may  be 
acute  or  chronic.  The  only  treatment  is  specific,  which  in  some 
cases  has  appeared  to  arrest  the  disease  (p.  659). 


THE  EAR. 

This   chapter   comprises   a   short   description    o^]^ Furuncle     of     the 
furunculosis  of  the  external  auditory  canal  .    .    .j     Auditory    Canal  p.  109 

.    .    .  A    succinct    resume    of   suppurative    otitis^ 
externa jOWis  externa  .    .   p.  no 

.    .    .  A  more  detailed  study  of  irritation  of  the  1  Intertrigo    of    the 
retro-auricular  fold,  which  is  a  true  intertrigo,  more  I     Retro-auricular 
or  less  complicated  with  eczema J      fold p.  no 

.    .    .  A   resume  of  the  evolution  in   this  jZ/wa-l  Chilblain     Erythe- 
tion,  of  chilblains  and  winter  erythema J      ma  pernio  .   .    .  p.  in 

.    .    .   Of    lupus    erythematosus    of    the    auricle  1 
which   is   closely    allied    to    the   preceding    wor&tjl^"P"^      erythema- 

^  tOSUS p.  112 

process      J  ^ 

.    .    .  Finally,  of  tuberculous  lupus,  which  is  more^ 
^g^^  I  Tuberculous  lupus  p.  113 

Cheloids  of  the  ear  are  common  after  piercing 
the  ears,  and  we  shall  speak  of  them  after  lupus, 
for  the  tuberculous  origin  of  these  lesions  has  been 
frequently    demonstrated 

JVe   shall   next   study    the    two    chief   forms    of^ 
eczema    of   the    ear:    impetiginous   eczema    of   the  j  Impetiginous      ec- 

temples  and  cheeks,   which   may   cause   secondary  [      zema P-  114 

invasion  of  the  pavilion  of  the  ear J 

Squamous  eczema  of  the  auditory  canal,  which^ 
most  authors  place  among  the  seborrheic  eczemas]^^^^^^^^^   eczema  p.  ns 

Molluscum    .    .    .  p 


Cheloid P-  "3 


Lastly,  the  ear  may  be  the  seat  of  rare  or  less 
important  lesions,  zvhich  zve  shall  briefly  refer  to   . 


Papilloma  .  .  .  .  p, 
Seborrhoea  .  .    .    .  p 

.Comedo p 

Gouty  Tophus  .  .  p 
Cancroid  .  .  .  .  p 
Leprous    tubercles  p 


n6 
n6 
n6 
n6 
n6 
n6 
n6 


FURUNCULOSIS    OF    THE    EXTERNAL    AUDITORY    CANAL. 

Furunculosis  of  the  external  auditory  canal  is  generally  ob- 
served after  external  otitis,  an  eczema  of  the  canal  or  neigh- 
bouring regions  having  given  rise  to  the  infection.  Furuncle 
of  the  ear  develops  with  the  characters  of  ordinary  furuncle; 
pain  is  excessive  and  strictly  limited  to  the  anterior  or  posterior 
part  of  the  canal  and  is  out  of  proportion  to  the  amount  of  pus 
which  is  evacuated.  The  evolution  of  furuncle  takes  from  6 
to  8  days,  but  after  the  first  boil  others  often  appear. 


no  THE   EAR. 

Diagnosis  is  made  by  the  aural  speculum,  which  reveals  a 
round  projecting  tumour  in  the  cavity,  very  painful  to  the 
touch. 

Medical  treatment  is  illusory.  Incision  of  the  central  part 
of  the  tumour  relieves  the  patient,  and  even  when  incomplete, 
diminishes  pain  and  congestion.  Strong  antiseptic  lotions  are 
contra-indicated.  To  prevent  recurrence,  applications  of  calomel 
ointment  (i  per  cent)  may  be  prescribed. 

SUPPURATIVE    OTITIS    EXTERNA. 

Suppurative  otitis  externa  is  common  in  children  of  3  to  10 
years  in  the  poorer  classes.  Its  commencement  is  acute  and  pain- 
ful ;   its    evolution    chronic,    and    it   lasts    for    months    or   years. 

Every  day  the  ear  discharges  a  few  drops  of  thick  or  serous 
pus  with  a  foetid  odour.  The  child  does  not  suffer,  the  parents 
neglect  it  and  the  disease  continues. 

It  is  possible  that  this  chronic  epidermatitis  may  lead  later  on 
to  thickening  of  the  tympanic  membrane,  analogous  to  the 
corneal  leucomas  left  after  phlyctenular  conjunctivitis.  Otitis 
externa  rarely  gives  rise  to  otitis  media  and  hardly  ever  to 
ulceration  of  the  membrane. 

Frequent  syringing  with  warm  boric  lotion,  or  oxyginated 
water  diluted  to  one-fifth,  give  excellent  results  when  the  treat- 
ment is  continued  for  some  time.  Whenever  such  an  affection 
does  not  quickly  improve  the  case  should  be  referred  to  an 
aurist. 

RETRO-AURICULAR  INTERTRIGO. 

This  affection,  which  is  very  common  even  in  the  adult,  but 
especially  in  children,  is  of  the  greatest  clinical  and  educational 
importance. 

Clinically,  it  is  an  intertrigo,  a  red  moist  epidermatitis,  limited 
to  the  retro-auricular  folds  and  to  the  borders  of  these  folds. 
Like  all  intertrigos  it  may  remain  with  its  original  characters, 
but  has  a  tendency  to  become  moist,  crusted  and  fissured.  It  is 
in  this  form  that  it  is  most  frequently  observed. 

The  fold  is  then  hidden  by  an  elongated  impetiginous  crust, 
under  which  is  found  the  macerated,  moist  epidermis,  covered 
with  a  pale  lilac  fibrinous  membrane.     By  drawing  the  ear  for- 


THE    EAR.  Ill 

wards  a  fissure  is  found  which  bleeds  easily.  These  lesions 
generally  persist  for  several  months. 

They  may  co-exist  with  chronic  impetigo  of  the  nose,  with 
acute  impetigo  of  the  face,  or  more  rarely  with  whitlow.  They 
may  be  superposed  on  an  eczema  of  the  same  region,  or  of  the 
face  or  scalp ;  or,  inversely  may  become  the  centre  of  a  neigh- 
bouring eczematisation. 

Culture  (p.  8)  shows  that  this  intertrigo,  like  all  intertrigos, 
is  streptococcic.  The  clinical  opinion  which  connects  this  lesion 
with  fatty  squamous  conditions,  wrongly  termed  seborrhoeic, 
is  without  foundation.  The  lesion  in  question  is  a  primary  im- 
petigo of  the  retro-auricular  fold,  or  secondary  to  a  pre-existing 
lesion  such  as  eczema. 

The  treatment  is  that  of  impetigo,  with  lotions  of  sulphate  of 
zinc  (i  per  cent)  or  nitrate  of  silver  (i  in  15)  ;  protective  pastes, 
etc.  It  is  liable  to  recurrence,  or  to  alternate  with  other  lesions 
of  the  same  nature  (see  impetigo  p.  7).  When  there  is  periph- 
eral eczematisation,  ointments  of  oxide  of  zinc  and  oil  of 
cade  are  excellent : — 

Oxide    of    zinc 1 

Oil  of  cade I    aa     5  grammes         3ifs 

Oil    of    birch •^ 

Ichthyol L   aa     i  gramme  gr.  16 

Resorcine       j 

Vaseline 1 

Lanoline |   aa  15  grammes  3j 


CHILBLAIN.     ERYTHEMA  PERNIO. 

Children,  adolescents  and  even  adults  (especially  women) 
present  every  winter  chilblains  of  the  ears.  These  occur  in  two 
forms,  diflfuse  and  localised.  The  diffuse  form  is  a  reddish 
purple  oedema,  very  congestive  and  affecting  the  pavilion  of 
the  ear  and  the  lobule,  sometimes  accompanied  by  superficial 
epidermic  desquamation.  This  "erythema  pernio"  persists  dur- 
ing the  cold  season.  The  localised  form  affects  the  margin  of 
the  ear  with  a  series  of  distinct  chilblains,  in  the  form  of  a 
chaplet,  each  consisting  of  a  hard  and  painful  oedematous  point. 
All  intermediate   forms  occur   between   these   two   forms,   and 


xia  THE    EAR. 

between   the   second   form   and   lupus   erythematosus   of   the   ear. 
There  is  no  treatment  for  chilblains.     Generally  the  tendency 
diminishes  as  the  patient  grows  older      Local  treatment  is  not 
very  efficacious,  but  the  following  may  be  tried: — 

Glycerole  of  Starch 30  grammes  3J 

Resorcine      1 

Tartaric  acid J     3°  centigrammes    gr.  5 

Menthol 15  "  gr.  ii 

General  treatment  by  sea  baths,  mineral  water  springs,  etc., 
is  theoretical.  They  may  possibly  do  some  good  and  can  do  no 
harm. 

LUPUS    ERYTHEMATOSUS. 

The  margin  of  the  ear  is  one  of  the  seats  of  election  of  lupus 
erythematosus. 

Clinically,    it 
often     follows 

^•rr  _ , t:  -«a&i^ - .  -'i's.-np^xiMi—  '*'>~^ . ^  chilblains  of  the 

^S^^^K  ^^I^^BK'  same  situation. 

*^^^^^  ^^^^^^fc.  j^.  occurs  usually 

as  a  series  of  red 
patches,     irregu- 
\m^^^^^^m^-  <ia^^H  larly  elongated 

i^^|^9^P  \  ^^^^R  ^"  '^^^  contour  of 

ij^  ^uI^Ha  the  concha,  situ- 

ated  in   the  hol- 
i^^h^HK-  '^^^■PKl  '^        lows,    and    bor- 

I^^^^HK^^  ^^^^^mS^       dered       with 

white,     adherent 

squamcs.      The 

atrophy    of    the 

.'^^■^^^^^^^^^^^^^^^^H^  skin    causes    the 

ear    to    appear 

emaciated,    a  n  d 

V  ^^^^^^^^^BB!^*^  --^  it  preserves   this 

appearance  after 
cure. 

Lupus   erythe- 

rig  45.     Lupus    erythematosus   of   the    cheek   and    ear  matOSUS  may 

(HUlalrot'Q    patient.     St.    Louis    Hosp.    Museum,  .    ^  ,       .       , 

No.  168.)  exist  exclusively 


THE    EAR. 


"3 


on  the  ears,  but  more  often  it  occurs  also  on  the  face  or  scalp 
(Fig.  45)- 
I  have  spoken  of  the  unsatisfactory  treatment  of  lupus  ery- 
thematosus (p.  19)  and  there  is  no  need  to  return  to  it. 
Radiotherapy  appears  to  be  the  only  one  of  any  value,  if  not 
in  all  cases,  at  any  rate  in  a  great  number. 

TUBERCULOUS   LUPUS. 

In    contra-distinction    to    lupus    erythematosus,   tuberculous 
lupus  is  generally  situated  on  the  lower  part  of  the  ear,  belov^f 

the  tragus. 

The  lobule  is  nearly  alw^ays 

■-     :-i-_^jii^^-  the  initial  and  principal  seat  of 

'  X  this    regional     localisation    of 

lupus,  which  is  somewhat  rare. 
The  lobule  is  much  increased 
in  size  and  the  lupus  nodules 
buried  in  the  neighbouring 
congestive  oedema  are  not 
easily  seen.  The  chronicity  of 
the  lesion  and  its  progressive 
development  indicate  the  diag- 
nosis. This  is  confirmed  by 
examination  of  the  lobule  com- 
pressed under  a  plate  of  glass, 
which  blanches  the  region  and 
renders  the  red  nodules 
apparent. 

Treatment,  apart  from  pho- 
totherapy (p.  21),  is  nearly 
exclusively  confined  to  the 
galvano-cautery,  by  means  of 
cauterisations  crossing  in  all  directions.  A  cure  is  easier  to 
obtain  than  in  many  other  forms  of  lupus.  After  cure,  the 
lobule  is  reduced  to  a  stump  and  has  a  skeletal  aspect  of  which 
the  patient  must  be  warned. 


rigr.  46.     Hypertrophic    lupua    of    the    ear 

and    Its    lobule.      (Hardy's    patient. 

St.    Louis    Hosp.    Museum, 

No.    299.) 


CHELOID. 

Cheloids,    like    lupus    or    papillomatous    tuberculosis,    which 
also  sometimes  occu-r  on  the  lobule  of  the  ear,  may  originate 


114 


THE    EAR. 


in  perforation  of  the  lobule  for  ear  rings.  This  operation  is  often 
performed    by    a    jeweller    with    a    dirty    instrument,    which    he 

sometimes  moistens  with  saliva. 
Under  these  conditions  infection 
is  possible,  especially  when  the 
operator  is  tuberculous. 

It  is  impossible  to  say  that  all 
cheloids  are  tuberculous,  but  the 
tuberculous  nature  of  a  great 
number  has  been  demonstrated 
by  positive  inoculation  in  the 
guinea  pig. 

The  cheloid  tumour,  in  this 
situation,  has  usually  the  form  of 
a  plum.  It  is  of  red  colour  and 
firm  to  the  touch,  showing  its 
fibrous  and  compact  structure. 

Cheloids,  in  this  situation  as  in 
all  others  (p.  625),  should  be 
treated  by  deep  linear  quadri- 
lateral scarifications,  or  by  radio- 
therapy.       Surgical      extirpation 

Figr.  47.    Cheloid  of  the  lobes  of  bothevcn    whcn    cxtcnsivc    and    anti- 
ears.     (Besnier'8    patient.     St.    Louis  .      ,  -  ,  -    -,  , 
Hosp.    Museum,    No.    1681.)                SCptlC,  haS  tOO  oftCU  bCCU  folloWCd 

by  recurrence  with  aggravation 
of  the  tumour  to  be  recommended,  however  simple  it  may 
appear  at  first  sight,  especially  in  such  a  situation  as  this. 


IMPETIGINOUS    ECZEMA. 


Impetiginous  eczema  of  the  ear  is  only  an  accessory  localisa- 
tion of  impetiginous  eczema  of  the  face  in  the  adolescent,  which 
so  often  accompanies  urinary  hypoacidity  and  transient  albuminuria 
(vide  p.  12). 

In  the  course  of  this  eczema  streptococcic  impetiginous 
infection  may  occur  secondarily.  One  then  finds  points  of  inter* 
trigo,  covered  W'ith  crusts,  in  the  folds  of  the  antero-external 
surface  of  the  ear,  and  also  retro-auricular  intertrigo,  (p.  no). 


THE    EAR. 
SQUAMOUS   ECZEMA. 


"S 


Squamous  eczema  is  limited  to  the  external  auditory  canal 
and  the  concavity  of  the  concha.  On  the  surface  of  the  skin, 
which  is  fatty  in  these  places,  there  are  squames,  semi-adherent 
to  the  subjacent  skin,  which  is  of  an  orange  red  colour. 

This  condition  is  found  in  association  with  simple  or  steatoid 
pityriasis  of  the  scalp,  naso-genial  furrow  and  beard  in  adoles- 


Flff.  48.     Epithelioma  of  the   commissure 

of    the    lobule    of    the    ear,    recurring 

after    operation. 

(Sabouraud's    patient.     Photo    by    Noirfi.) 


Tig.  49.     The  same  patient  after  cure  by 

the     X-rays.     Observe     the     alopecia 

produced  by  radiotherapy. 


cents  with  a  fatty  skin,  which  is  also  often  affected  with  poly- 
morphous acne  of  the  face  and  commencing  seborrhcea  of  the 
forehead  and  vertex.  It  is  also  seen  at  middle  age  in  fat  men 
with  dry  eczema  of  the  beard  and  scalp. 


Ii6  THE    EAR. 

This  condition  is  very  liable  to  recur  but  is  easily  remedied 
by  tar  ointments,  pine  tar  being  in  this  case  superior  to  oil  of 
cade.     Examples : — 

Liquid  tar   purified  ...    ."1 

Oleum    theobromae   ...    .J  ^  ^    ^^^  ^ 

or,  Yellow  oxide  of  mercury    j  ^^  30  centigrammes      gr.  7 

Resorcme J 

Liquid    tar 4  grammes              3  i  fs 

Lanoline 20         "                        3j 


MOLLUSCUM.   PAPILLOMA.   COMEDO.   TOPHUS.   CANCROID. 

In  addition  to  the  preceding  affections,  the  ear  may  be  the 
seat  of  more  uncommon  lesions.  In  the  child,  molluscum  conta<- 
giosum  is  sometimes  seen  (p.  129)  ;  in  the  adult,  papillomatous 
warts.  The  concha  of  the  ear  is  a  seat  of  election  for  comedos. 
The  margin  of  the  ear  presents  in  the  gouty  a  chaplet  of  chalky 
tophi,  which  has  some  resemblance  to  the  chaplet  of  chilblains 
in  the  adolescent.  Lastly,  very  rarely,  chronic  epithelial  ulcer, 
or  epithelioma,  may  be  situated  here  as  on  senile  seborrhoeic 
faces  (p.  31).  This  has  two  common  situations,  the  margin 
of  the  ear  and  the  commissure  which  separates  the  lobule  from 
the  cheek.    The  latter  is  represented  in  Figures  48  and  49. 

TUBERCULAR   LEPROSY. 

Leprous  tubercles  are  observed  on  both  ears  in  nearly  all  cases 
of  leontiasic  leprosy  (vide  Fig.  10,  p.  22)). 

The  tubercles  are  the  size  of  a  pea,  indurated  and  raised,  with 
a  slow  evolution  interrupted  by  acute  paroxysms  of  pseudo- 
erysipelas.  They  are  disseminated  throughout  the  lobule,  the 
size  of  which  is  doubled,  and  around  the  margin  of  the  ear, 
with  the  same  characters  as  on  the  face.  They  only  represent 
a  common  epiphenomenon  in  tubercular  lepros}^  but  may 
become  of  diagnostic  value  at  the  onset  of  the  disease.  Local 
treatment  presents  nothing  peculiar.  The  treatment  of  leprosy 
is  summed  up  on  p.  24. 


THE   FOREHEAD. 

The  forehead  presents  dermatoses  peculiar  to  the  smooth 
regions  of  the  face,  and  also,  on  account  of  its  situation  between 
the  eyebrows  and  the  hair,  some  of  the  lesions  of  hairy  regions. 
This  gives  a  peculiar  interest  to  its  dermatological  study. 


The  supra- superciliary  region  is  one  of  the  first] 
to  present  the  manifestations  of  seborrhoea,  «;/»tc/»  I  Seborrhcea  .  .   .   .  p.  ii8 
may  extend  later  to  the  whole  forehead J 

Polymorphous  acne  occurs  here,  as  in  all  smooth^ 
regions |Acne    polymorphe  p.  ii8 

The  supra- superciliary  regions  are  also  a  place  of] 
election  for  the  small  lesions  of  follicular  /»i'/'^»'- r  Keratosis      pilaris  p.  IIQ 
keratosis,  commonly  called  keratosis  pilaris  .   ,   .J 

The  forehead  is  one  of  the  regions  of  the  face^ 
where  miliary  juvenile  flat  wart  is  most  often  seen  J  ^^^^   wart  ....  p.  II9 

Also,   in  young  people,   pityriasis   of   the  scalp  j  Corona  Seborrhoi- 
often  extends  onto  the  forehead  and  forms  the  red  f- 
squamous  border  of  the  corona  seborrhoica  ...    .1 


p.  120 


These   comparatively   benign   lesions   are   some-^ 


times    confounded    zvith    the    crown    of    copper- yCorow^i   Veneris  .  p.  121 
coloured  papules  caused  by  secondary  syphilis  ,   , 

Seborrhoea   of   the   forehead  is   depilatory,   and  \ 
when   it   reaches   the    temples   causes   denudation,  [■  Frontal  baldness  .  p.  121 
which  precedes  or  accompanies  common  baldness  .J 

In  women,  seborrhoea  and  acne  together  denude^ 
the  border  of  the  scalp  along  the  forehead  from  one  L  Frontal     Alopecia  p.  122 
temple  to  the  other 

The  forehead,  especially  at  the  temples,  is  often')  c     u 

the  seat   of  papular  secondary  syphilides,   in   the  I       .yr ,  ^^ 

u        X  \       ilides o.  122 

corymbose  form *^ 

In  the  same  situation  is  often  seen  lupus  erythe-~\  Lupus     erythema- 
matosus,  with  cicatricial  evolution  and  scaly  borders  j     tosus p.  123 

At  mature  age  acne  necrotica  forms  varioloid  le--\    . 

.,     r  ,  J  ^1     X      1     J     J- Acne  necrotica  .  .  p.  121 

sions  trt  the  form  of  a  crown  round  the  forehead  .  j  *-      o 

Also  acne  hypertrophica,  with  its  projections  ond"]  Acne    hypertroph- 
bosses J      ica p.  124 

On    the   forehead    tertiary   ulcerative   syphilides^  Tertiary      Syphil- 
form  arborescent  ulcers J      ides P- 125 

In  old  age  the  temples  are  a  seat  of  election  for^  _  .  ,    ,. 
fenile  warts  and  epithlioma |  Epithelioma   .    .   .  p.  125 


ii8  THE   FOREHEAD. 

We  need  not  do  more  than  mention  the  lesions  of  moUuscum 
contagiosum,  the  patches  of  cutaneous  trichophytosis,  tubercu- 
lous lupus,  etc.,  which  may  occur  here  as  elsewhere,  without 
occurring  with  sufficient  frequency  to  merit  special  attention. 
Opthalmic   Zona   will   be   studied   with   lesions   of   the   eyelids. 

SUPRA-SUPERCILIARY    SEBORRHOEA. 

The  forehead,  next  to  the  nose,  is  one  of  the  first  regions  in 
which  seborrhoea  occurs,  characterised  by  exaggerated  sebaceous 
secretion  and  dilatation  of  the  sebaceous  pores,  which  are  filled 
with  a  fatty  cylinder  containing  a  colony  of  the  specific  micro- 
bacillus. 

This  seborrhoea  is  symmetrical  above  the  eyebrows.  The 
affected  surfaces  often  coalesce,  the  forehead  becomes  diffusely 
seborrhoeic  and  the  infection  may  invade  the  hairy  scalp  (p.  211). 
Here,  as  elsewhere,  seborrhoea  preserves  its  chronic  symptoms 
and  evolution  (p.  13).  In  seborrhoea  of  the  forehead,  different 
forms  are  found  according  to  the  case  observed ;  the  severe 
or  fluent  form,  which  is  common  in  the  forehead  and  face,  the 
treatment  of  which  we  have  already  considered  (p.  14)  ;  the  form 
with  comedo  and  polymorphous  acne,  of  which  we  have  studied 
the  different  forms  and  treatments  in  other  regions  of  the  face 
(P-  95)- 

ACNE   POLYMORPHE 

Polymorphous  acne  is  common  enough  to  merit  a  special  para- 
graph, but  as  its  characters  are  identical  with  those  of  poly- 
morphous acne  occurring  elsewhere,  this  paragraph  will  be  very 
short. 

On  the  forehead  one  may  observe  together  or  separately,  acne 
comedo,  acne  punctata,  indurata,  pustulata ;  and  in  rare  cases 
even  phlegmonous  and  cystic  acne. 

Whenever  acne  occurs  on  the  forehead  with  abundance,  it  also 
exists  on  the  nose,  cheeks  and  trunk.  Acne  of  the  forehead  is 
only  an  epiphenomenon. 

When  localised  only  on  the  forehead  it  should  always  suggest 
acne  necrotica  (acne  frontalis  of  Hebra,  p.  123).  The  treatment 
is  identical  with  that  of  acne  of  the  face.  (p.  95). 


THE    FOREHEAD.  .        119 

KERATOSIS    PILARIS. 

Keratosis  pilaris  must  be  distinguished  from  seborrhoea  and 
acne,  and  will  be  studied  more  in  detail  with  affections  of  the 
eyebrow  (p.  139)  ;  but  it  often  presents  a  supra-superciliary  frontal 
localisation. 

On  a  semilunar  space,  4  centimetres  wide  and  3  in  height,  are 
situated  a  number  of  follicular  hyperkeratotic  points,  surrounded 
with  a  red  ring  after  friction,  or  when  the  subcutaneous  circula- 
tion is  increased.  This  condition  occurs  also  in  the  temporal 
region  and  in  the  external  pre-auricular  and  maxillary  portion 
of  the  cheek. 

This  condition,  which  appears  to  be  distinct  from  seborrhcea, 
is  sometimes  connected  with  it  and  is  then  observed  on  the 
forehead,  especially  over  the  eyebrows  and  at  the  border  of  the 
hairy  scalp. 

The  skin  is  greasy  and  dotted  everywhere  with  the  gaping  ori- 
fices of  sebaceous  glands,  sometimes  occluded  by  a  comedo.  But 
a  great  number  of  sebaceous  orifices  are  hidden  by  a  small  cone 
of  hyperkeratosis,  more  or  less  raised  and  distinct. 

This  condition  resists  all  ordinary  treatment  for  acne,  and 
requires  keratolytic  applications,  such  as : — 

Salicylic  acid 1 

Resorcine       ^  aa  i  to  3  grammes  gr.  16-48 

Precipitated     Sulphur    •    •    •  J 

Vaseline      30  grammes  3j 

Ointments  with  sulphur  or  oil  of  cade  may  also  be  used  after 
washing  with  soft  soap  for  a  quarter  of  an  hour  to  two  hours. 
Prolonged  treatment  is  necessary  and  recurrence  frequent.  The 
proportions  of  the  medicaments  employed  should  be  altered 
according  to  the  resistance  of  the  skin  of  the  patient. 

(See  Keratosis  pilaris  of  the  eyebrows,  p.  139;  and  Frontal 
Alopecia,  p.  122). 

JUVENILE    FLAT    WART. 

Juvenile  flat  w^arts  may  be  situated  anywhere,  even  on  the 
hands  or  body,  but  they  are  more  common  on  the  face,  especially 
on  the  forehead.    They  may  occur  in  the  infant,  but  more  gener- 


120  THE   FOREHEAD. 

ally  at  the  sexual  age.  They  appear  to  become  attenuated  and 
disappear  generally  at  adult  age. 

They  occur  in  the  form  of  a  crop  of  very  small  papules,  nearly 
contiguous,  or  disseminated  in  rows.  Each  wart  is  shiny,  of  a 
yellowish  red  colour,  from  half  to  one  millimetre  in  diameter, 
with  sharp  borders  projecting  from  the  skin  from  34  to  3^  a 
millimetre.  Very  often  they  form  regular  trails  extending  from 
a  traumatic  erosion  or  scratch,  and  a  scratch  with  a  needle  is 
soon  covered  with  them.  They  thus  appear  to  be  contagious, 
but  the  parasite  is  unknown. 

They  may  be  removed  by  the  galvano-cautery  applied  super- 
ficially so  as  not  to  leave  a  scar.  Lotions  of  salicylic  acid  (2  per 
cent)  sometimes  give  favourable  results.  A  better  application 
is  sulpho-carbolic  acid,  applied  with  a  hard  brush  and  repeated 
daily. 

CORONA    SEBORRHOICA. 

When  the  hairy  scalp  is  covered  by  steatoid  pityriasis  with 
fatty  pellicles  (p.  208)  it  is  not  uncommon  for  the  pityriasis  to 
extend  beyond  the  margin  of  the  hairy  scalp  and  form  more 
or  less  marked  circinations  on  the  forehead. 

These  lesions  encroach  on  the  smooth  skin  for  3^  to  i 
centimetre,  rarely  more.  This  is  the  Corona  Sehorrhoica  of 
Unna,  consisting  of  a  figured  steatoid  pityriasis.  The  lesion  is 
constituted  by  very  slight  thickening  and  redness  of  the  skin, 
which  is  finely  scaly  and  covered  with  small  yellow  pellicles, 
which  leave  a  grease  spot  on  blotting  paper. 

In  rare  cases,  not  only  the  corona  seborrhoica  exists,  but 
similar  patches  occur  on  the  forehead  and  temples  in  the  midst 
of  smooth  skin,  also  on  the  eyebrows  and  glabellum.  Steatoid 
pityriasis  has  a  tendency  to  difTusion,  sometimes  even  to  general- 
isation. (Seborrhoeic  Eczema  of  Unna).  It  is  nearly  always 
seen  also  in  the  naso-genial  furrow  (p.  97)  and  the  mid-sternal 
region. 

The  treatment  is  that  of  steatoid  pityriasis  of  the  hairy  scalp 
(p.  208).  Applications  of  ichthyol,  resorcine,  oil  of  cade  and 
sulphur  give  excellent  results,  but  must  be  continued  for  a 
long  time  to  give  permanent  results. 

Very  resisting  cases  should  be  treated  like  psoriasis ;  viz..  by 
preparations  containing  pyrogallic  acid  or  hydroquinone    (i   in 


THE   FOREHEAD.  I21 

30).     Soap  should  be  avoided  in  removing  these  ointments,  as  it 
may  cause  staining. 

SECONDARY    SYPHILIS.      CORONA    VENERIS. 

Secondary  syphilis  may  affect  the  forehead  indifferently,  as 
any  other  region  of  the  body,  by  roseola,  papular  and  papulo- 
tubercular  syphilides,  etc.  But  there  often  occurs  in  the  course 
of  secondary  syphilis,  around  the  hairy  scalp,  a  series  of  spots, 
sometimes  so  crowded  as  to  form  a  crown.  This  may  be  con- 
founded by  the  novice,  with  the  preceding  lesion,  or  vice  versa. 
The  syphilitic  lesions  are  papular,  flat,  copper  coloured,  not 
squamous  and  almost  surrounded  by  a  very  fine  desquamation, 
(the  "collar  of  Biett").  This  lesion  may  be  observed  in  the 
absence  of  any  analogous  lesion  of  the  hairy  scalp,  which  does 
not  occur  in  the  case  of  corona  seborrhoica.  Also  the  presence  of 
other  syphilitic  lesions  must  be  determined.  At  this  stage  of 
syphilis  they  are  almost  always  present.  Search  must  be  made 
for  the  initial  lesion,  the  enlarged  glands,  roseola,  secondary 
papules  on  the  body,  mucous  patches,  alopecia,  etc. 

Local   treatment  is  illusory;  general  treatment  is   important. 


RECEDING  OF  THE  FOREHEAD  BY  SEBORRHOEA  AND 

BALDNESS. 

At  the  same  time  that  diffuse  depilation  commences  on  the 
vertex  in  young  people,  foretelling  those  who  will  later  on 
become  bald  (18  to  25  years),  one  sees  the  forehead  recede 
little  by  little  for  a  few  millimetres  and  expose  the  temples  by 
denudation,  forming  two  more  or  less  deep  notches  and  enlarging 
the  forehead  at  the  expense  of  the  hairy  scalp.  Examination 
with  a  lens  shows  invasion  of  the  region  with  seborrhoea,  with  all 
its  characters,  at  the  same  time  as  the  depilation.  The  surface 
is  glossy,  with  an  overproduction  of  fat,  especially  towards  night ; 
the  sebaceous  pores  are  enlarged  and  present  cylinders  of  fat 
which  can  be  expressed  by  scraping  with  the  edge  of  a  glass 
slide,  or  between  the  nails. 

The  treatment  of  this  localisation  of  seborrhcea  is  the  same 
as  for  seborrhoea  in  other  situations,  sulphur  and  tar  being  the 


122  THE   FOREHEAD. 

most  useful  remedies.  Washing  with  soap  may  be  done  at 
night,  but  this  at  first  appears  to  increase  the  seborrhoeic  phe- 
nomenon. 

Solvents  of  fats,  such  as  acetone  and  ether,  may  be  applied  on 
absorbent  wool,  but  these  medicaments  are  only  palliative.  This 
form  of  seborrhoea  and  the  depilation  which  accompanies  it  are 
very  little  influenced  by  any  kind  of  treatment. 

FRONTAL    ALOPECIA    OF    WOMEN. 

In  young  girls,  between  the  ages  of  15  and  20,  affected  with 
seborrhoea  of  the  face,  an  invasion  of  the  whole  border  of  the 
hairy  scalp,  from  one  temple  to  the  other,  and  about  an  inch 
in  width,  is  sometimes  produced  by  a  morbid  condition  which 
appears  to  be  a  mixture  of  keratosis  pilaris  and  seborrhoea,  which 
I  have  just  mentioned  (p.  119).  This  eruption,  which  is  estab- 
lished in  the  course  of  a  few  months,  is  accompanied  by  diffuse 
alopecia  of  a  corresponding  band  of  the  hairy  scalp. 

The  whole  surface  of  the  skin  is  fatty  and  covered  with  small 
horny  elevations,  more  or  less  marked,  corresponding  to  the 
hairy  follicles.  The  skin  between  the  hairs  is  often  scaly,  so  that 
the  lesion  has  the  appearance  of  a  combination  of  keratosis 
pilaris,  steatoid  pityriasis  and  seborrhoea.  In  a  few  months 
this  alopecia  is  nearly  complete  over  the  whole  of  a  frontal 
band,  about  an  inch  in  width.  The  process  gradually  subsides, 
after  destruction  of  the  hairs,  the  skin  becomes  smooth  and  the 
hair  follicles  which  have  lost  their  hairs  undergo  a  progressive 
sclerosis  which  causes  their  entire  disappearance. 

The  treatment  of  this  affection,  for  which  we  are  nearly 
always  consulted  too  late,  is  that  of  pityriasis,  seborrhoea  and 
keratosis  pilaris  (p.  119).  The  most  active  treatment  consists 
in  the  application  of  ointments  containing  sulphur,  oil  of  cade 
and  salicylic  acid ;  and  cleansing  every  morning  with  a  fat  sol- 
vent, such  as  acetone  and  ether.  The  lesion  when  once  estab- 
lished is  irreparable. 

SECUNDO-TERTIARY     CORYMBOSE     SYPHILIDES. 

Papular  or  papulo-tuberculous  syphilides  of  the  corymbose 
form  are  late  secondary  manifestations,  which  may  be  observed 
on  the  forehead  and  temples.  Sometimes  the  eruption  is  situ- 
ated half  on  the  smooth  skin  and  half  on  the  hairy  scalp.    It  is  an 


1^ 


THE   FOREHEAD.  123 

efflorescence  of  4  to  20  elements,  disposed  in  the  form  of  a 
more  or  less  regular  bouquet.  The  elements  are  brown,  round, 
flat,  slightly  raised  and  of  the  size  of  a  lentil.  They  are  slow  in 
disappearing  and  often  last  for  months  in  the  same  place  with- 
out apparent  change,  a  characteristic  by  which  they  dififer  from 
other  analogous  secondary  eruptions,  which  are  always  much 
less  stable. 

These  late  secondary  eruptions  give  evidence  of  insufficient 
treatment  and  require  a  new  treatment  better  carried  out,  by 
inunction  or  injections  (p.  513).  Iodides  appear  to  have  an 
vmcertain  action  in  these  cases,  nevertheless  they  may  be  com- 
bined with  mercurial  preparations. 

LUPUS  ERYTHEMATOSUS. 

Lupus  erythematosus  presents  on  the  forehead  the  same  char- 
acters which  we  have  described  in  other  regions  of  the  face 
(p.  18).  It  is  always  in  the  form  of  a  white,  depressed,  cicatricial 
patch,  marbled  with  brown,  bordered  with  red,  and  scaly  at 
the  circumference.  The  peculiar  symptoms,  indefinite  dura- 
tion and  cicatricial  evolution,  and  the  co-existence  of  similar 
lesions  in  other  places,  in  normal  cases,  hardly  leave  any  doubt 
as  to  the  diagnosis,  even  to  the  novice.  But  typical  cases  occur 
which  may  puzzle  the  best  dermatologists.  We  cannot  describe 
here  these  exceptional  forms.  In  doubtful  cases,  when  the 
objective  signs  of  a  lesion  are  abnormal,  remember  that  the 
evolution  of  a  dermatosis  is  quite  as  characteristic  as  its 
objective  form.      (For  treatment  see  p.  19). 

ACNE  NECROTICA.   ACNE  FRONTALIS  OF  HEBRA. 

The  forehead  is  one  of  the  seats  of  election  of  acne  necrotica. 
It  sometimes  begins  and  always  occurs  here,  sometimes  exclu- 
sively. It  generally  occurs  on  the  forehead  at  the  same  time  as 
on  the  nose  (p.  96),  the  scalp  (p.  235),  and  the  chest  (Fig.  195 
and  p.  477).  In  each  case  it  is  characterised  by  a  discrete  or 
profuse  eruption  of  similar  elements.  These  commence  like 
a  pustule  of  circumpilary  impetigo  (impetigo  rodens)  of  Hillairet- 
Gaucher)  ;  but  the  pustules  enlarge  and  increase  in  diameter. 

The  flat  discoid  crust,  fixed  in  the  skin,  remains  there  for 
several  weeks.     It  finally  becomes  detached  and  falls  with  the 


124 


THE  FOREHEAD. 


hairs  which  pierce  it,  leaving  a  strongly  marked  and  indelible 
cicatrix.  I  have  described  the  nature  of  acne  necrotica  elsewhere. 
It  is  a  pustule  of  impetigo  of  Bockhart,  superposed  on  seborrhoeic 
infection  of  the  follicle  which  forms  the  centre  of  the  pustule. 

The  frontal  eruption  of  neucrotic  acne  eventually  forms  a 
crown  of  cicatrices,  more  numerous  near  the  temples  than  in  the 
centre.  This  eruption  occurs  in  crops  of  varying  degrees  and 
duration.  Treatment  cures  for  a  time  but  does  not  prevent 
recurrence.  I  have  already  mentioned  the  treatment  of  necrotic 
acne  of  the  smooth  parts  (p.  96)  ;  I  shall  refer  to  its  treatment 
when  dealing  with  eruptions  of  the  scalp  (p.  235). 

ACNE   HYPERTROPHICA. 


Acne  of  the  period  of  involution  is  sometimes  accompanied  by 
passive  venous  stasis,  a  kind  of  congestive   oedema,   or   quasi 

neoplastic  infiltration,  a 
good  example  of  which 
is  seen  in  rhinophyma. 
This  condition  may  be 
more  rarely  observed 
on  the  cheeks  and  fore- 
head (Fig.  50). 

Treatment  is  the 
same  as  for  acne  hyper- 
trophica  of  the  nose 
(p.  103).  We  may  add, 
to  what  we  have  said, 
compression  of  the 
region,  which  is  possi- 
ble here,  with  an  elastic 
dressing  which  aids 
absorption  of  the  infil- 
tration and  causes  in  a 
few  days  a  better 
appearance.  This  con- 
dition is  always  very 
chronic,    slowly    pro- 

Fii;.  50.     Acr.e   Hypsrtrophica:    pf,   fissure:    mh,    hy-        p-regsive    and    aot    tO    re- 
perplasia.      (Besnier's    patient.      St.    Louis    Hosp.  '-  ^ 

Museum.  No.  1287.)  cuf  after  treatment. 


THE   FOREHEAD.  125 

FRONTAL    TERTIARY    SYPHILIDES. 

Tertiary  frontal  syphilides  belong  to  the  type  of  gummata  in 
placards.  They  are  common  and  characteristic,  but  often  mis- 
understood. At  first  they  form  red  or  purple  placards,  irregular 
in  shape  and  form,  with  a  slightly  mammillated  surface.  In  the 
second  stage  the  nodosities  become  ulcerated  and  covered  with 
a  greenish  brown  adherent  scab,  under  which  is  found  a  sharp 
cut,  grey  and  moist  ulceration,  which  bleeds  easily.  These  ulcer- 
ations often  fuse  together  and  become  extensive,  forming  radiat- 
ing ulcerations  with  curious  configuration.  External  treatment 
has  no  efifect.  Internal  mixed  treatment  gives  good  results  in  a 
few  weeks. 

The  lesion  disappears,  leaving  an  arborescent  white  cicatrix, 
which  forms  a  probable,  but  not  absolutely  certain  retrospective 
diagnosis  of  syphilis  to  the  practised  eye. 

EPITHELIOMATOSIS. 

The  forehead  of  old  people  with  fatty  skins,  especially  in  the 
temporal  regions,  shows  a  propensity  for  senile  warts  and  epithe- 
lial degenerations.  It  is  at  these  points  that  cutaneous  epithe- 
liomas most  often  occur,  in  the  non-ulcerated  pearly  form,  or  the 
ulcero-crustaceous. 

The  characters,  evolution  and  treatment  of  these  lesions  has 
been  already  mentioned  and  there  is  no  need  to  repeat  them 
here  (p.  105). 

VARIA. 

The  forehead  is  one  of  the  regions  where  impetigo  contagiosa 
(p.  7)  ;  chloasma  (p.  26)  and  ephelides  (p.  5)  are  most  com- 
monly observed. 


THE  EYELIDS. 

The    eyelid    presents    for    consideration    simpler  c--      i     i_i     t.     •.•  ^ 

7     ,  J      a;  J  ui  ,.1       f  L  Simple   blepharitis  p.  126 

catarrh,  known  under  the  name  of  blepharitis  .    .    .j        " 

.  Also    chronic   ciliary   pustular   blepharitis,]  . 

,  .  ,      ,  .  J  .      ■  •       /    Chronic      pustular 

which  often  precedes  and  accompanies  sycosis  of  V     ,  ,     ,      .\ 

'        ,  blepharitis    .      .   p.  127 

the   moustache J 

We  shall  next  study  syphilitic  chancre  of  the  cyc-^  Chancre     o  f     the 
lid,  which  is  less  rare  than  commonly  supposed  .    .]      eyelid P- 127 

.    .    .  And    syphilitic    blepharitis,    which    accom-^  Secondary     syphi- 
panies   secondary    eruptions J      litic     blepharitis  p.  128 

The  painless  intra- palpebral  tumour,  of  slow  evo--^ 
lution,  which  oculists  call  chalazion,  merits  a  fezv  1  Chalazion    ....   p.  128 
words  of  description 

.    .    .  Also   the   small  soft   umbilicated   tumours^  Molluscum    conta- 
of  molluscum  contagiosum J     giosum p.  129 

.    .    .  And  the  grains  of  milium,  which  are  fre-^ 
quently  seen  in  the  eyelids J 

After  this,  we  shall  study  xanthoma  of  the  eye-^ 
lids,  zvhich  forms  a  small  yellozv  painless  />/acard  h  Xanthelasma  .  .    .  p.  130 
of  chronic  evolution J 

And  opthalmic  zona,   the  vesicular  branches   om 
which   may    cover,   not   only    the   eyelid,    but   a/.yo  ^  Opthalmic  Zona    .  p.  131 

the  forehead J 

on  alopecia  of  the  eyelashes -^  Alopecia    of    eye- 

We  shall  end  this  chapter  by  saying  a  few  words  j     lashes P-  131 

.    .    .   Ciliary  phtiriasis,  which  is  rare  but  ncces-^     .... 
sary  to  know jPhtinasis    ....  p.  132 


Lastly,  cicatricial  contractions  of  the  eye- 


lid, generally  after  lupus 


I  Ectropion P- 132 


SIMPLE    BLEPHARITIS. 

In  simple  blepharitis  the  borders  of  the  eyelids  are  red  and 
slightly  itching,  with  a  pricking  sensation  when  waking  at  night. 
During  the  night  the  eyelids  become  glued  together  and  in  the 
morning  they  are  crusted  and  smarting,  and  the  ocular  con- 
junctiva is  injected. 

Blepharitis  is  probably  a  common  microbial  infection.     It  has 
been  said  to  be  rheumatic  in  origin,  which  might  mean  somethin;^ 
if  rheumatism  was  defined.    This  blepharitis  is  recurrent  once  o 
twice  a  year  in  certain  subjects.    The  attacks  last  about  two  or 


THE   EYELIDS.  127 

three  months.  Treatment  consists  in  frequent  bathing  with  warm 
Vichy  water  to  dissolve  the  crusts,  and  with  saline  solution  to 
diminish  congestion.  At  night  red  oxide  of  mercury  ointment  is 
applied    (3^  per  cent). 

PUSTULAR    BLEPHARITIS.      STYE. 

The  elementary  lesion  of  this  form  of  blepharitis  is  the  stye, 
a  pustular  ciliary  folliculitis.  The  stye  may  be  single  and  often 
recurs.  It  is  more  common  in  children  but  occurs  in 
adolescents  and  in  adults.  It  may  become  chronic,  when 
the  eyelashes  are  agglomerated  in  tufts  and  the  ciliary  border 
is  covered  with  recurrent  styes.  In  the  inner  angle  of  the  eye 
a  drop  of  pus  is  found  in  the  morning.  Eventually  the  eyelashes 
are  expelled  by  deep  folliculitis  and  the  palpebral  border  becomes 
chronically  red,  atrophic  and  smooth.  This  pustular  blepharitis 
is  included  among  the  stigmata  of  lymphatism.  If  lymphatism 
and  scrofula  are  defined,  like  tubercle,  by  the  bacillus  of  Koch, 
this  opinion  is  wrong,  for  the  lesions  are  not  tuberculous.  Apart 
from  this  erroneous  definition  lymphatism  has  hardly  any  other. 
Certain  individuals  show  a  predisposition  to  invasion  of  the 
mucous  membranes  by  pyogenic  microbes,  but  we  know  nothing 
of  the  nature  of  this  predisposition. 

The  conjunctivitis  accompanying  this  blepharitis  is  treated  by 
instillations  of  sulphate  of  zinc  (2  per  cent)  twice  a  day.  The 
pustules  should  be  opened  and  cauterised  with  nitrate  of  silver 
(i  in  15).  Irrigation  with  saline  solution  and  moist  dressings 
at  night  give  good  results.  The  affection  is  very  chronic  and 
recurrent.     It  often  precedes  an  anterior  rhinitis. 

CHANCRE   OF   THE   EYELID. 

The  initial  lesion  of  syphilis  is  less  rare  on  the  eyelids  than 
one  would  at  first  imagine.  It  is  in  fact  a  professional  chancre 
and  almost  special  to  metal  workers.  In  these  occupations  a 
hard  fragment  often  gets  into  the  eye  of  the  workman  and 
causes  small  erosions  of  the  palpebral  conjunctiva.  It  is  the 
custom  with  the  workmen  to  remove  these  fragments  with  the 
moist  end  of  a  cigarette  taken  from  the  mouth.  This  is  the 
origin  of  most  palpebral  chancres. 

They  generally  occupy  the  palpebral  border  and  develop 
chiefly  at  the  expense  of  the  mucosa,  causing  eversion.     The 


128  THE    EYELIDS. 

chancre  forms   a  hard,  red,  fleshy   induration,  eroded   but   not 
ulcerated,   and   with   little   discharge.     The   development   takes 


Fig.  51.     Syphilitic   chancre   of   the   upper   eyelid. 
Before  and  after  treatment.      (LaiUer's  patient.      St.  Louis  Hosp.  Museum,  No.  84.) 

about  two  or  three  weeks,  and  the  pre-auricular  gland  becomes 
enlarged,  hard,  and  painless.  The  lesion  is  sometimes  of  con- 
siderable size,  but  entirely  disappears  under  treatment.  Anodyne 
lotions  of  Vichy  water  or  camomile  may  be  applied  locally. 

SECONDARY  SYPHILITIC  BLEPHARITIS. 

This  co-exists  with  roseolar  and  papular  eruptions,  and  gen- 
erally with  papular  eruptions  of  the  face.  The  conjunctivae 
are  injected  and  the  eyelids  have  lost  their  regular  curve,  owing 
to  the  border  being  raised  in  places  by  papules. 

The  co-existence  of  the  eruption  on  the  face  should  indicate 
the  diagnosis,  which  is  confirmed  by  roseola  of  the  body,  enlarged 
glands  and  the  presence  of  the  initial  lesion. 

CHALAZION. 

Chalazion  is  said,  without  absolute  proof,  to  be  an  acne  of  the 

Meibomian  glands.    The  anatomical  seat  of  the  lesion  is  certain, 

but  not  its  nature.     It  forms  a  small  tumour,  resembling  acne 

indurata,  of  chronic  progressive  evolution,  sometimes  stationary, 


THE   EYELIDS. 


129 


sometimes  retrogressive ;  the  total  duration  being  from  6  months 
to  2  years.  When  once  established  it  may  not  undergo  resolution. 
The  treatment  of  chalazion  belongs  to  the  oculist  and  consists 
in  curetting  the  tumour  on  its  palpebral  surface ;  a  simple  opera- 
tion which  is  always  successful.  Chalazion  does  not  recur  in 
the  same  place,  but  the  same  eyelid  may  be  afifected  by  several. 

MOLLUSCUM    CONTAGIOSUM. 

Molluscum  contagiosum  is  a  small  benign  tumour  of  the  skin 
of  various  sizes,  from  that  of  a  millet  seed  to  that  of  a  pea. 
The  tumours  are  soft,  sessile,  raised  and  umbilicated.    They  may 


Fig.  52.     Molluscum   contagiosum   of   the   eyelids. 
(Thiblerge's    patient.     St.    Louis    Hosp.    Museum,    No.    1672.) 


occur  on  all  parts  of  the  body  and  are  mentioned  among  the 
general  dermatoses  (p.  621).  They  are  more  common  on  the  face 
and  I  describe  them  with  the  eyelid  on  account  of  the  fine  exam- 
ple shown  in  the  figure  (Fig.  52).  There  are  often  20  or  30 
tumours  in  the  same  region.  At  other  times  they  are  few  and 
disseminated.      They    must    not    be    confounded    with    milium. 


130 


THE    EYELIDS. 


The  treatment  is  simple  and  consists  in  extirpation  by  a 
sharp  curette.    The  operation  causes  very  Httle  pain  or  bleeding. 

MILIUM. 

Milium  is  often  seen  in  the  eyelids,  especially  in  women,  and 
at  about  the  50th  year.  Each  grain  of  milium  {horde olatiim) 
is  a  small  white  cyst  resembling  a  grain  of  barley  set  in  the  skin. 
It  is  of  no  importance  and  never  becomes  the  origin  of  epithe- 
lioma. 

Treatment  is  only  aesthetic  and  consists  in  opening  each  cyst 
with  a  fine  galvano-cautery  and  expressing  the  contents.  If  they 
recur  each  cyst  may  be  touched  with  tincture  of  iodine  applied 
on  a  wooden  stylet. 


XANTHOMA.     XANTHELASMA. 

Xanthelasma  may  occur  on  the  body  (p.  632)  and  on  any  part 
of  the  face,  but  its   most  common  situation   is   the   inner  half 

of  the  upper  eyelid. 
The  lower  lid  is 
affected  secondarily. 

The  lesion  of 
Xanthelasma  is  very 
peculiar.  It  forms 
under  the  skin,  a 
flat  slightly  mamil- 
lated  tumour  of  a 
yellow  colour. 

This  lesion  is 
c  h  r  o  n  i  c,  nearly 
always  symmetrical, 
never  retrogresses 
and  increases  slowly. 
It  is  of  no  impor- 
tance and  never 
degenerates.  It  is 
seldom  observed 
before  40,  and  occurs 

Fig.  53.     Xanthoma     (Darier's     patient.     St.     Louis  :„    Vv/->fVi     eovoc       "PTJc 

Hosp.    Museum,    No.    1600.)  J"     UOtn    SeXCb.      ms- 


THE   EYELIDS. 


131 


tologically   it  is  a   special   disease   the   nature   of  which   is   not 
known. 

Treatment  consists  in  a  series  of  punctures  with  a  fine  gal- 
vano-cautery  at  intervals  of  one  or  two  millimetres.  The  lesion 
disappears  after  three  sittings  with  intervals  of  a  fortnight. 

OPTHALMIC    ZONA. 

We  are  ignorant  of  the  nature  and  origin  of  zona.  It  is  dis- 
tributed in  the  region  of  the  opthalmic  branch  of  the  trigeminal. 

Like  all  zonas  it  is  unilateral,  and 
the  corymbose  pustules  may 
cover  the  frontal  region,  the  hairy 
scalp,  the  temporal  region,  the 
eyelids  and  the  globe  of  the  eye, 
on  one  side. 

The  pustules  on  the  eye  are 
extremely  dangerous.  They  are 
nearly  always  accompanied  by 
hypopion,  a  crescent  of  pus 
accumulating  in  the  lower  part 
of  the  anterior  chamber  of  the 
eye.  There  is  therefore  great  risk 
of  panopthalmitis,  but  this  is  not 
of  very  frequent  occurrence. 

There  is  no  treatment  for  zona. 
Glycerole  of  starch  and  zinc  paste 
have  little  value  and  it  is  doubtful 
if  the  most  rational  treatment  of 
the  eye,  by  permanent  warm  compresses,  has  any  action  in  pre- 
venting the  occurrence  of  hypopion  or  panopthalmitis.  A  pro- 
tective dressing  has,  however,  the  advantage  of  easing  photo- 
phobia and  putting  the  eye  at  rest. 

After  disappearance  of  the  zona,  the  persistent  neuralgia  may 
be  treated  with  a  spray  of  chloride  of  methyl,  which  has  given 
good  results. 

CILIARY   ALOPECIA. 

Partial  or  total  loss  of  the  eyelashes  is  usually  an  epiphe- 
nomenon  in  the  course  of  generalised  alopecia.     It  then  partic- 


Fig.  54.     Ophthalmic    Zona. 

(Danlo's     patient.      St.     Louis     Hosp. 

Museum,    No.    1871.) 


132  THE    EYELIDS. 

ipates  in  the  general  course  of  the  disease,  and  its  prognosis  is 
the  same. 

I  have  once  seen  an  alopecia  of  a  single  palpebral  border 
occurring  suddenly  in  a  nervous  patient.  It  continued  for  about 
four  months  and  the  eyelashes  grew  again  almost  spontaneously. 
One  can  hardly  advise  daily  local  applications  on  the  ciliary 
borders  when  there  is  general  alopecia  requiring  much  attention. 
In  these  cases  I  simply  order  an  ointment  of  red  oxide  of  mer- 
cury (i  per  cent).  In  localised  ciliary  alopecia  a  lotion  of  lactic 
or  acetic  acid  may  be  applied  with  a  wooden  match.  (Alcoholic 
solution  of  lactic  acid  i6  per  cent). 

PEDICULOSIS. 

Pediculosis  of  the  eyelashes  is  rare.  It  is  seldom  seen  except 
in  people  who  take  little  care  of  their  person  and  are  for  a 
long  time  infected  with  pediculi  pubis.  It  is  always  the  phthirius 
pubis  which  is  seen  in  the  eyelids.  This  should  be  thought  of 
in  cases  of  blepharitis,  of  which  the  cause  is  not  apparent,  for  the 
lice  hanging  on  to  the  palpebral  border  are  not  easily  seen. 

Treatment  consists  in  removing,  under  a  lens,  each  parasite 
and  each  hair  bearing  an  &gg. 

ECTROPION. 

Ectropion  is  eversion  of  the  eyelid  produced  by  a  contractile 
cicatrix.  It  occurs  after  tuberculous  lupus  of  the  cheek,  after 
epithelioma  and  after  burns  of  the  face,  etc.  It  can  only  be  cured 
by  a  plastic  operation. 

When  very  pronounced  the  eye  remains  uncovered  during  sleep 
and  ulcerations  of  the  cornea  may  occur. 


THE  EYE. 

Of  the  whole  pathology  of  the  eye  the  dermatologist  need 
only  be  thoroughly  acquainted  with  a  few  types. 

The  first  is  interstitial  keratitis,  which  is  a  stigmas  Interstitial  Kera- 
of  hereditary  syphilis J      titis p.  133 

The  second  is  phlyctenular  impetigo,  which^  Phlyctenular  Ker- 
accompanies  or  follows  impetigo  of  the  face  ■    •    -j      atitis P- I33 

The  third  is  secondary  syphilitic  iritis Syphilitic  iritis  .  .  p.  134 

INTERSTITIAL    KERATITIS. 

Interstitial  keratitis  is  a  sign  of  hereditary  syphilis.  At  an 
excentric  point,  generally  in  its  lower  part,  the  cornea  is  ren- 
dered opaque  by  a  bluish  white  interstitial  deposit,  more  marked 
in  the  centre  of  the  patch  and  diminishing  towards  the  periphery. 
It  is  always  a  lesion  of  childhood,  but  may  become  gradually 
accentuated. 

In  this  white  deposit  is  often  seen  a  group  of  dark  spots  of 
variable  size  formed  by  anterior  synechia  of  the  iris. 

This  lesion  occurs  without  other  symptoms  than  progressive 
diminution  of  vision  when  the  corneal  opacity  reaches  the  centre 
of  the  pupil. 

Specific  treatment  does  not  improve  this  lesion  after  it  is  once 
established  but  vision  may  often  be  restored  by  iridectomy. 
For  the  dermatologist  it  is  an  important  element  of  retrospective 
diagnosis. 

PHLYCTENULAR   KERATITIS. 

Phlyctenular  keratitis  is  the  impetigo  of  the  eye.  It  consists 
in  an  erosion  of  the  cornea  resulting  from  an  impetiginous 
phlyctenule,  most  often  arising  in  the  course  of  impetigo  of  the 
face.  It  is  accompanied  by  intense  photophobia  and  lachryma- 
tion. 

The  child,  more  or  less  covered  with  impetiginous  crusts  or 
alTected  with  impetiginous  coryza  with  nasal  discharge  (p.  7), 
holds  the  head  obliquely,  the  affected  eye  being  held  lower  or 


^34 


THE    EYE. 


closed.  On  separating  the  eyelids  the  conjunctiva  is  found 
to  be  suppurating,  the  eye  injected  and  the  surface  of  the  cornea 
abraded  by  the  small  erosive  lesion  of  the  impetiginous  phlycte- 
nule. 

This  lesion  when  neglected  lasts  a  long  time ;  several  lesions 
are  produced  in  succession  and  the  affection  may  persist  for  four 
or  six  months.  Each  erosion  leaves  a  permanent  bluish  corneal 
opacity.  On  the  contrary,  when  properly  treated  the  lesions 
disappear  without  leaving  a  trace. 

Instillations  of  sulphate  of  zinc  (i  per  cent),  repeated  several 
times  a  day,  and  warm  compresses  constitute  the  best  treatment 
in  this  affection. 

SYPHILITIC    IRITIS. 

There  is  a  recurring  iritis  called  rheumatic,  because  the  cause 
is  unknown ;  also  iritis  is  sometimes  seen  in  the  course  of  different 
infectious  manifestations,  such  as  recurrent  scarlatiniform 
erythema ;  it  has  even  been  described  in  the  course  of 
gonorrhoea ;  but  the  most  common  and  most  characteristic  form 
of  iritis  is  that  of  secondary  syphilis. 

It  may  appear  soon  after  the  roseola,  but  generally  occurs 
later  and  may  be  seen  at  any  time  during  the  first  year  of  syphilis. 

It  presents  itself  as  a  circum-corneal  ring  of  congestion,  often 
taken  for  a  cold  in  the  eye,  and  not  very  painful.  When  examined 
in  this  stage  the  pupil  is  already  irregular,  presenting  a  notch 
at  some  part  of  its  circumference.  If  the  mobility  of  the  iris  is 
tested  by  suddenly  opening  the  eye,  the  effort  which  the  pupil 
makes  to  contract  exaggerates  the  deformity. 

The  lesion  is  constituted  by  an  inflammatory  fibrinous  exuda- 
tion on  the  posterior  surface  of  the  iris,  causing  immobility.  At 
the  pupillary  orifice  may  be  seen  posterior  synechise,  appearing 
as  a  flaky  deposit. 

This  lesion  requires  intense  treatment  by  injections  of  grey 
oil  or  calomel  (p.  49).  It  is  the  custom  to  apply  emplastrum 
of  Vigo  or  grey  ointment  to  the  region  of  the  temple ;  but  the 
injections  are  more  important. 

When  properly  treated  the  lesion  retrogresses  and  is  cured  in 
two  or  three  weeks.  The  iris  regains  its  mobility  and  vision  is 
perfect.     But  when  badly  treated,  or  treated  too  late,  the  iritis 


THE    EYE.  135 

leaves  permanent  synechise  and  the  pupil  remains  deformed. 
The  iris  is  not  always  affected  alone,  the  choroid  being  often 
attacked.  Irido-choroiditis  is  recurrent  and  may  cause  perma- 
nent disorders  in  the  fundus  oculi.  But  choroiditis  belongs 
to  the  domain  of  the  oculist  and  will  not  be  studied  here. 


THE   EYEBROWS. 

The  eyebrow  presents  for  examination,  first  an] 

insufficient  development   for  which   ive  are   ^ow^- 1  Atrichia P- 136 

times  consulted J 

.    .    .   Or    an    exaggerated    development    v.'hich'\ 
unites  the  eyebroivs  in  the  middle  line |  Hypertrichosis    .    .  p.  136 


Like  all  hairy  regions  the  evcbroiv  is  a  scat  of^ 
ection  for  pityriasis    ....'. jSteatoid    Pityriasis  p.  137 

.    .    .and  for  moist  ecsema  ivhich  may  follozu  it    Eczema P-  I37 

These  conditions  are  often  foUotvcd  by  an  alo--^ 
pccia  which  must  be  recognised  and  treated  .    .    .j-P'tyroid    Alopecia  p.  138 


election  for  pityriasis J  " 

.    .    .and  for  moist  ecsema  ivhich  may  follozu  it    Eczema P-  I37 

These  conditions  are  often  follotved  by  an  alo- 

The  eyebrow  is  the  seat  of  election  of  a  peculiar] 
disease  characterised  by  a  slight  hyperkeratosis  0/ [-Keratosis  pilaris   .  p.  139 
the  hair  follicle  and  atrophy  of  the  hair J 

The  line  of  the  eyebrow  is  a  point  zvhcre  a  con-^  Cyst    of    the    eye- 


} 


genital  cyst  may  occur j      brow p.  139 

It  is  one  of  the  regions  where  secondary  syphilitic^ 
alopecia  assumes  one  of  its  special  forms |Syphihtic    alopecia  p.  140 

Alopecia    of    the    eyebrows   must   be    recognised]  . ,         •  ft] 

although  it  is  generally  only  an  epiphenomenon  ofr  • 

severe  alopecia J 

Lastly,  the  eyebrow  is  one  of  the  situations  where'] 
tubercular   leprosy   first   appears |  Leprous    tubercles  p.  141 


ATRICHIA  AND    HYPERTRICHOSIS. 

Some  young  girls  complain  that  their  eyebrows  are  too  pale  and 
too  scanty.  Generally  they  are  blondes  with  fine  hairs.  A  stimu- 
lating lotion,  such  as  the  following,  may  be  ordered : — 

Tincture  of  Jaborandi 25  grammes     3j 

Alcohol  90  per  cent 250  "  3j 

Extract  of  violets 25  "  3j 

Acetic  acid  lotions  may  also  be  given,  which  have  a  tendency  to 
darken  the  hair : — 

Glacial   Acetic   Acid i  part 

Hoffmann's    Liquor 50  parts 

On  the  other  hand,  some  girls  complain  that  the  eyebrows  join 
in  the  middle  line.    These  are  hypertrichotic  brunettes  presenting 


THE   EYEBROWS.  137 

in  different  places  a  visible  downy  growth.  Electrolysis  is  the  only 
treatment  for  this  condition  and  should  be  confined  to  the  large 
hairs,  leaving  the  pale  down  alone(  p.  5),  This  improves  the  con- 
dition and  removes  the  severity  of  expression  caused  by  this  slight 
disfigurement. 

STEATOID    PITYRIASIS. 

The  eyebrow  behaves  like  a  detached  portion  of  the  hairy  scalp,  of 
which  it  may  present  all  the  principal  affections,  especially  the  pel- 
licular diseases. 

Pityriasis  of  the  eyebrow  generally  accompanies  steatoid  pityri- 
asis of  the  scalp  (p.  208).  On  turning  back  the  hairs  of  the  eyebrow, 
one  sees  thick  yellow  soft  pellicles,  which  may  extend  slightly  beyond 
the  hairy  region.  This  condition  is  permanent  with  exacerbations. 
The  fatty  condition  of  the  squames  is  more  or  less  marked ;  some- 
times they  are  nearly  dry,  sometimes  greasy. 

This  pityriasis  is  nearly  always  diffuse,  rarely  occurring  in  circles 
or  semi-circles.  In  the  latter  case  there  are  pityriasic  circles  on  the 
forehead  and  naso-genial  furrow. 

Treatment  consists  first  in  the  application  of  ointments  of  tar  or 
sulphur,  the  action  of  which  is  rapid : — 

(i)   Precipitated    Sulphur 

Resorcine 

Essence    of    verveine     

Vaseline 

(2)    Oil  of  cade 

Oil    of   birch 1 

Ichthyol ^aa 

Resorcine •-' 

Lanoline 

Vaseline 

These  ointments  are  applied  at  night  and  washed  off  in  the  morn- 
ing. Good  results  are  also  obtained  by  daily  friction  with  coal  tar 
in  Eau-de-Cologne  (i  in  7). 

ECZEMA. 

Steatoid  pityriasis,  on  the  eyebrows  as  elsewhere,  is  often  the 
origin   of   subjacent   eczematisation,   giving   rise   to   discharge   and 


I  gramme 

gr.  16 

q.3. 

30  grammes 

3J 

5  grammes 

5ii  fs 

I  gramme 

gr.  20 

10  grammes 

5v 

IS  grammes 

5J 

138  THE    EYEBROWS. 

crusts.  The  same  phenomenon  occurs  in  the  moustache  (p.  147  )> 
the  beard  and  scalp  (p.  215)  ;  and  sometimes  eczematisation  is  pro- 
duced in  all  these  places.  The  functional  phenomena  are  pruritus, 
heat  and  exudation,  the  latter  forming  thick  crusts  occupying  the 
exact  position  of  the  eyebrow  and  glueing  its  hairs  into  a  single 
mass.  This  eczema,  limited  to  the  hairy  regions,  shows  the  same 
tolerance  to  medicaments,  such  as  tar  and  sulphur,  as  pityriasis. 
These  are  applied  in  the  form  of  ointments,  by  massage : — 
(i)   Oil   of  birch ^ 

Resorcine L  aa  I  gramme     gr.  16 

Ichthyol .J 

Oil  of  Cade 10  grammes       5  iv 

Lanoline 20  grammes  3J 

(2)    Precipitated    Sulphur 

Resorcine aa  i  gramme       gr.  16 

Ichthyol     

Vaseline 30  grammes  5J 

In  the  morning  these  are  washed  off  with  very  mild  soap  applied 
with  a  badger  hair  brush ;  or  sweet  oil  of  almonds  may  be  applied 
first  on  absorbent  wool. 

When  there  is  recurrence,  local  hygienic  treatment  for  pityriasis 
should  be  applied. 

PITYROID    ALOPECIA. 

The  eyebrow  undergoes  periodical  moulting,  but  presents  besides 
a  more  or  less  marked  alopecia  accompanying  steatoid  pityriasis. 
An  eyebrow  may  thus  lose  a  quarter  or  a  third  of  its  size  by  a 
diffuse  alopecia  accompanying  the  evolution  of  pellicles.  An  almost 
complete  alopecia  may  occur  after  eczema. 

This  alopecia,  like  those  which  follow  pityriasis  in  all  situations, 
is  curable  by  the  therapeutic  methods  which  act  against  its  cause — 
tar  or  sulphur  ointments  (p.  137).  When  the  cause  has  disappeared 
the  ointments  may  be  replaced  by  alcoholic  frictions  of  the  type  of 
those  which  are  useful  in  pellicular  alopecia  of  the  scalp: — 

Coal-tar    (Saponified)   .    . 


} 


aa  25  grammes          Jj 
Extract  of  violets 

Alcohol :  60   per    cent  ....  200           "                 5j 

Nitrate  of  potash 50  centigr.        gr.  j 

Distilled    water 50  grammes        3ii 

Bichloride  of  Mercury  ....  30          "        gr.  H 


THE    EYEBROWS.  139 

Alopecia  of  the  eyebrow  may  become  in  hereditary  neurotics  or 
the  overworked,  the  origin  of  phobias  of  the  type  we  shall  speak  of 
later  (p.  145). 

KERATOSIS    PILARIS. 

Keratosis  pilaris  appears  to  be  an  affection  resulting  from  a  con- 
genital cutaneous  dystrophy,  but  which  is  especially  marked  in  the 
second  period  of  infancy,  becoming  more  and  more  apparent  during 
adolescence.  The  lesions  are  first  seen  when  the  face  is  flushed  by 
exercise  or  emotion.  The  cheeks  and  temples  up  to  the  line  of  the 
eyebrow  as  well  as  the  supra-superciliary  regions  are  covered  with 
red  points  consisting  of  horny  follicular  elevations,  conical  and  trun- 
cated, and  each  surrounded  by  a  minute  red  areola.  In  repose  these 
dots  are  much  less  apparent  and  of  a  yellow  barley  sugar  colour. 
After  friction  they  become  red  and  prominent.  The  hairs  of  the 
modified  region,  emerging  from  the  horny  cone,  are  seen  to  be  dys- 
trophic and  downy.  When,  as  is  the  rule,  the  temporal  and  supra- 
superciliary  affection  invades  the  eyebrow  externally,  this  process  is 
accompanied  by  progressive  atrophy  of  the  line  of  the  eyebrow 
(Brocq).  In  severe  cases  only  the  internal  part  of  the  eyebrows 
remain,  resembling  the  supra-orbital  feathers  of  an  owl.  These 
dry,  slightly  inflammatory  lesions  terminate  in  follicular  sclerosis 
and  permanent  disappearance  of  the  hairs,  leaving  a  punctiform 
cicatrix. 

This  affection  has  been  connected  to  keratosis  pilaris  of  the  back 
and  arms,  but  is  not  quite  identical  and  often  does  not  occur  in  the 
eyebrows  of  patients  whose  arms  are  covered.  It  has  also  a  rela- 
tionship to  the  pseudo-alopecia  of  Brocq  (p.  224). 

Treatment  by  reducing  agents,  such  as  sulphur,  salicylic  acid  and 
resorcine  is  the  only  satisfactory  one.  Strong  doses  must  be  used 
to  erode  and  exfoliate  the  horny  epidermis: — 

Salicylic  acid "| 

Resorcine I  aa  i  to  5  parts     gr.  16  to  3jfs 

Precipitated  Sulphur  .    .J 

Vaseline 5j 

This  is  applied  at  night  and  washed  off  in  the  morning. 

CYST    OF   THE    EYEBROW. 

This  congenital  deformity,  for  which  the  dermatologist  is  some- 
times consulted,  is  fairly  common.    At  the  line  of  the  eyebrow  and 


140  THE    EYEBROWS. 

a  little  above  it  is  a  small  tumour  the  size  of  a  pea  or  nut  which  per- 
sists without  causing  symptoms.  It  is  due  to  imperfect  obliteration 
of  part  of  a  branchial  cleft.    The  treatment  is  surgical. 


SYPHILITIC   ALOPECIA. 

The  alopecia  of  secondary  syphilis  may  aflfect  all  the  hairs  of  the 
body.  It  is  sometimes  characteristic  on  the  eyebrows,  and  it  is  not 
uncommon  for  the  clinician  to  diagnose  syphilis  from  this  appear- 
ance. 

It  resembles  a  series  of  snips  by  scissors  made  transversely  and 
dividing  the  eyebrows  in  pieces.  It  is  especially  marked  on  the  inner 
half  of  the  eyebrow.  The  hairs  are  easily  removed  by  the  fingers. 
The  scalp  at  the  same  time  presents  parietal  alopecia  in  patches 
(p.  228) .  On  the  body  and  mucous  membranes  there  are  other  signs 
of  syphilis. 

Local  treatment  may  be  given  if  the  patient  desires  it  (as  in 
pityroid  alopecia  (p.  133),  but  general  treatment  is  the  only  one  of 
importance,  and  the  patient  should  be  informed  that  the  disease  is 
not  cured  when  the  eyebrows  have  grown  again. 


.ALOPECIA  AREATA   OF  THE   EYEBROW. 

Alopecia  areata  of  the  eyebrow  has  no  clinical  characters,  and 
only  occurs  in  conjunction  with  the  same  affection  of  the  beard  and 
scalp.  Usually  the  eyebrows  present  circumscribed  or  diffuse 
patches,  in  severe  cases  of  alopecia  areata  of  the  scalp  or  beard  pro- 
gressing towards  total  baldness.  Also  in  old  cases  of  alopecia  areata 
a  single  patch  may  exceptionally  occur  in  the  eyebrow.  The  Alo- 
pecia areata  of  the  eyebrow  is  thus  only  an  episode  in  the  course  of 
the  more  general  affection,  which  we  shall  study  on  the  scalp 
(p.  219)  and  in  all  hairy  regions. 

Local  treatment  is  the  same  as  for  the  scalp,  and  the  skin  of  this 
region  usually  supports  the  same  medicaments  in  the  same  doses. 

Growth  of  the  eyebrows  almost  always  follows  that  of  the  patches 
on  the  scalp,  and  treatment  of  the  eyebrows  in  cases  of  general 
alopecia  may  be  comparatively  neglected  till  regrowth  of  the  hair  is 
obtained. 


THE    EYEBROWS.  141 

LEPROUS    TUBERCLES. 

Tubercular  leprosy,  of  which  we  have  already  spoken  (p.  23) 
and  which  causes  the  leonine  face,  begins  generally  in  the  eyebrow 
in  the  form  of  irregularly  disseminated  intra-cutaneous  nodules, 
causing  falling  of  the  hairs.  These  nodules  rarely  ulcerate,  but  gen- 
erally persist  or  increase  in  size  and  number  to  form  a  moniliform 
tumour  occupying  the  whole  extent  of  the  eyebrow.  At  this  time 
the  appearance  of  the  rest  of  the  face  is  enough  to  make  a  diag- 
nosis of  the  disease  (Fig.  10). 

I  shall  refer  briefly  to  the  general  clinical  history  of  leprosy  with 
other  exotic  diseases  (p.  655). 


THE  REGION  OF  THE  MOUSTACHE. 

Young  girls   or  young  women  consult   the  phy-^ 
sician,  because  the  down  on  the  upper  lip  has  o"  I  Hypertrichosis  n  142 

excessive    development J 

Young    men,    because    the    development    of    thc-\ 
moustache  is  insuMcient j- Atrichia p.  145 

In  other  cases  the  hairs  of  the  moustache  present^  -r  •  t.      i.     ■ 

,     ■  ■  ,      ,       .     ^      ..,/..        i  richorrhexis    no- 

numerons  nodosities  at  the  level  of  which  the  hairsl      ■, 

break  off " J      ^^^"      P"  ^^ 

.     .     .     Or  the  hairs  are  divided  in  the  form  of^ 
a  brush       J-Trichoptilosis     .    .  p.  145 

In    the    latter   case    falling    of    the    hair    occurs.-\  p,    ,  •  r     p- 

which   in    neurotic   persons   may  give   origin    to   a  }       •     • 

,  ,  ,  I      riasis p.  145 

severe  fright       .' 

The  moustache  is  often  affected  with  pellicular^ 
affections  or  pityriasis,  dry  or  fatty J- Pityriasis p.  146 

Some  neurotics  epilate  themselves  without  reason \ 
thus  causing  an  artificial  alopecia _]  Trichotillomania    .  p.  146 

The  moustache  may  be  the  seat  of  the  weeping-^ 

eczema     with    greenish    yellow    crusts,    generally  l-^Q^ema P- I47 

limited  to  the  hairy  regions J 

The  moustache  is  also  the  seat  of  pustular  affec-^ 

tions,     of    considerable     importance    and     difficult  I  Sycosis p.  149 

treatment J 

It  may  be  attacked  by  alopecia  areata Alopecia  areata     .  p.  150 

Lastly  it  presents,  although  rarely,  a  parasitic  dis-^ 
ease  characterised  by  the  imbedding  of  hairs  in  a  [  Piedra  nostras  .       p.  151 
hard  greenish  brown  substance  of  a  dirty  appearanceJ 

HYPERTRICHOSIS. 

Young  girls  or  young  women  consult  the  physician  for  removal 
of  the  down  on  their  upper  lip.  These  cases  are  of  different 
degrees. 

In  the  case  of  a  uniform  fine  downy  growth  the  application 
of  oxygenated  water  is  sufficient  to  render  it  invisible.  A  series  of 
10  applications  is  made  with  absorbent  wool  moistened  with 
pure  oxygenated  water,  with  intervals  to  allow  the  last  applica- 
tion time  to  dry. 

If  there  are  large  hairs  scattered  at  intervals,  or  a  true  moustache, 
the  only  efficacious  remedy  is  electrolysis  of  each  hair.     Certain 


THE  REGION  OF  THE  MOUSTACHE  143 

ladies  prefer  the  indefinite  use  of  the  epilation  forceps,  but  the  hair 
thus  removed  always  grows  again  and  slowly  increases  in  size. 

The  larger  hairs  may  be  destroyed  by  electrolysis  and  the  sub- 
jacent down  bleached  as  above. 

In  all  cases  epilation  by  pastes  or  liquid  depilatories  is  to  be  con- 
demned. They  leave  the  lip  blue,  as  after  shaving;  they  are  pain- 
ful, require  frequent  renewal,  and  give  the  lip  the  appearance  of  an 
imperfect  beard. 

Radiotherapy  is  not  indicated  here  to  provoke  epilation,  for  it 
only  acts  on  adult  hairs  and  not  on  down.  It  is  thus  much  easier 
to  remove  the  moustache  of  a  man  than  the  downy  growth  of  a 
woman.  The  latter  seldom  falls  without  radiodermic  erythema,  and 
grows  again  three  months  later. 

Electrolysis  for  the  destruction  of  hairs,  being  most  often 
employed  for  removal  of  the  moustache  in  women,  may  be  de- 
scribed in  detail  here.  The  necessary  instruments  are:  (i)  A  bat- 
tery of  small  cells  with  a  continuous  current  of  regular  action; 
(2)  a  rheostat;  (3)  a  milliamperemeter ;  (4)  a  positive  pole  con- 
sisting of  a  metallic  cylinder  covered  with  chamois  leather  and 
moistened  with  salt  water ;  ( 5 )  a  negative  pole  with  the  electroly- 
tic needle,  as  fine  as  a  pig's  bristle,  slightly  blunt  at  the  end,  and 
bent  to  45°  at  ^  inch  from  the  point. 

The  needle  is  introduced  in  the  follicle  up  to  the  hair  papilla,  the 
patient  holding  the  positive  cylinder.  After  4  to  10  seconds  a  lit- 
tle froth  appears  at  the  hairy  orifice  indicating  destruction  of  the 
hair.  The  hair  then  comes  away  without  resistance.  A  current 
of  4  to  10  milliamperes  may  be  used  according  to  the  size  of  the 
hair.  As  a  rule  4  or  5  milliamperes  are  sufficient.  The  best 
operators  may  destroy  30  hairs  at  a  sitting,  allowing  for  3  or  4 
failures,  which  have  to  be  repeated.  The  patient  should  be  in- 
formed of  the  slowness  of  this  method  and  the  number  of  sittings 
which  are  necessary.  There  are  generally  three  times  as  many 
hairs  on  a  given  surface  as  were  at  first  expected.  Electrolysis 
after  destroying  the  large  hairs  may  cause  a  supplementary  de- 
velopment of  the  down,  but  this  is  rare. 

ATRICHIA. 

In  certain  young  men  the  moustache  grows  slowly  and  scantily. 
These  cases  are  often  hereditary  and  cause  much  distress  in  certain 


144  THE  REGION  OF  THE  MOUSTACHE. 

neurotic  subjects.  Revulsive  and  stimulating  applications  may  be 
prescribed,  but  without  giving  a  guarantee  as  to  the  result;  which 
is  always  slight.    But  the  prescription  may  have  a  moral  effect. 

(i)  Alcohol  60  per  cent.  ...  \ 

Acetone      J     ^^    ^5  grammes  aag  U 

Glacial    Acetic    Acid  ...                  50  centigrammes  gr.  v 

(2)   Hoffmann's     Liquor  ...                   50  grammes  5J 

Distilled    water ~1 

TT  J      vi      ^      r     I  1 25  centigrammes  aa  m  11 

Hydrochlorate  of  pilocarpme  .   .    .  J   ^  ^ 

Nitrobenzine 5  drops  m  vii 


TRICHORRHEXIS  NODOSA. 


This  peculiar  affection,  which  is  rather  common  on  the  moustache, 
is  always  more  marked  there  than  on  the  beard,  where  it  is  some- 
times observed.  It  is  more  rare  on  the  scalp.  The  cases  differ  con- 
siderably in  degree. 

Slight  cases  are  often  not  noticed.  In  medium  cases  the  mous- 
tache is  rough  and  presents  hairs  broken  at  different  lengths,  and  a 
multitude  of  fine  white  points.  Each  of  these  white  points  is  a 
nodosity  on  the  hair.  Some  hairs  show  from  two  to  six  in  a  row,  at 
unequal  intervals,  for  3  or  4  centimeters  of  the  length  of  the  hair. 
There  may  be  hundreds  of  such  hairs,  which  break  off  at  one  of  the 
nodosities  when  pulled  upon,  presenting  a  brush  like  end  {trichop- 
tilosis). 

In  very  marked  cases  the  moustache  is  short  and  rough  as  if  cut 
by  scissors,  where  the  hairs  are  broken  off.  These  cases  are  always 
the  result  of  bad  treatment.  The  moustache  has  a  russet  aspect  and 
the  hair  appears  artificial  and  relaxed. 

The  hair,  examined  by  the  microscope,  shows  changes  which  ex- 
plain the  fracture,  although  they  differ  very  much  from  the  naked 
eye  appearance  (Fig.  55). 

The  etiology  of  trichorrhexis  nodosa  is  obscure.  A  microbial  ori- 
gin has  been  suggested,  but  this  is  not  proved.  All  we  know  is  that, 
in  certain  individuals,  daily  washing  with  soap  is  sufficient  to  cause 
this  change.     But,  on  the  microbial  theory,  washing  with  soap  is 


THE  REGION  OF  THE  MOUSTACHE.  145 

increased  and  the  points  of  trichorrhexis  multiply.     It  is  thus  that 
all  severe  cases  are  caused.    On  the  other  hand  cases  occur  on  mous- 


Fig.  56.     Moustache  hairs  with  nodosities  of  trichorrhexis,  and  after  fracture  at 

these  points.     Magnified   60   diameters. 

(Preparation   by  Sabouraud.     Photo  by  Nolr6.) 


taches  which  have  never  been  soaped  and  the  origin  of  these  is 
doubtful. 

TRICHOPTILOSIS. 

This  alteration  of  the  hair  is  of  mechanical  origin  caused  by  too 
frequent  brushing  and  soaping,  etc.  Certain  hairs,  more  fragile 
than  the  others,  appear  to  be  particularly  predisposed.  There  is 
no  further  treatment  than  for  trichorrhexis  nodosa.  The  affected 
hairs  should  be  cut  and  brilliantine  applied. 

PHOBIA  OF  PITYRIASIS. 

Certain  adolescents  and  adults  consult  the  physician  on  account 
of  continued  loss  of  the  hairs  of  the  moustache.  These  patients  are 
invariably  nervous  nosomaniacs  and  the  loss  of  hair  is  a  delusion. 


146  THE    REGION    OF   THE    MOUSTACHE. 

Examination  shows  either  a  slight  degree  of  local  pityriasis;  or 
the  loss  of  only  three  or  four  hairs  altogether. 

Treatment  should  be  directed  against  the  nervous  condition  by 
assuring  the  patient  that  he  will  not  lose  his  moustache  and  that  the 
daily  loss  of  hair  is  normal.  Prescribe  daily  friction  with  an  anti- 
septic alcoholic  lotion  which  will  correct  the  pityriasis  and  act  as  a 
moral  remedy. 

Alcohol  60  per  cent 250  grammes  5j 

Soirit  of  lavender  .    .    . 


,-aa  25  "  5j 

Coal  Tar  (saponified) 

Bichloride   of   Mercury    .    .  30  centigrammes     gr.  ^ 

Explain  to  the  patient  his  nervous  condition  and  his  delusion  and 
direct  the  re-education  of  his  will  power  on  this  point.  He  should 
get  rid  of  his  fixed  idea,  as  he  made  it. 


TRICHOTILLOMANIA. 

Some  patients,  of  the  same  nosomaniac  group  as  the  preceding, 
consult  the  physician  for  alopecia  of  the  moustache.  They  complain 
of  local  itching  and  tingling  and  other  subjective  symptoms;  "when 
they  touch  a  hair  it  comes  out  by  itself,"  etc. 

These  are  neurotics  with  pityriasis  in  this  region  as  well  as  on  the 
scalp  and  eyebrows,  in  whom  local  itching  has  caused  a  mania  for 
epilation.  They  pull  out  hair  after  hair  to  see  if  it  is  affected,  thus 
causing  bald  patches,  which  in  turn  leads  to  further  epilation  of  the 
supposed  diseased  hairs. 

These  neurotics,  who  are  generally  intelligent,  should  be  informed 
of  the  mechanism  of  their  mania,  and  be  given  a  local  anti-pellicular 
treatment. 

PITYRIASIS. 

When  the  moustache  is  fully  developed  it  frequently  becomes  in 
the  adolescent  and  the  adult  the  seat  of  a  pellicular  affection  limited 
to  the  region  of  the  skin  which  it  covers : — pityriasis. 

This  affection  occurs  in  other  situations  and  will  be  specially 
studied  with  diseases  of  the  hairy  scalp  (p.  207).     In  the  moustache 


THE    REGION    OF   THE    MOUSTACHE.  147 

it  occurs  in  two  forms,  dry  and  fatty.  The  dry  form  pityriasis  sim- 
plex is  rare  and  unimportant,  consisting  of  some  local  itching  and 
fine  floury  scales,  produced  by  scratching. 

Tke  fatty  form,  pityriasis  steatoides,  is  more  common  and  more 
unpleasant  and  forms  numerous  semidetached  epidermic  scales,  yel- 
lowish and  greasy,  disseminated  between  the  hairs  at  their  base. 
The  aflfection  is  accompanied  by  itching  and  the  loss  of  5  to  10 
hairs  a  day,  which  does  not,  however,  cause  visible  alopecia,  much 
less  total  loss  of  the  moustache. 

Steatoid  pityriasis  of  the  moustache  is  usually  a  local  manifesta- 
tion of  a  similar  disease  affecting  all  the  hairy  regions  and  some 
smooth  areas,  such  as  the  intermammary  region  and  the  naso-genial 
fold. 

The  etiological  conditions  are : — adolescence,  the  male  sex ;  a  skin 
with  a  fatty  tendency ;  blonde  or  red  hair ;  an  easily  excitable  vaso- 
motor system  and  habitual  congestive  reflex.  Pityriasis  is  common 
in  overfed  persons. 

The  microbial  flora  is  constant,  and  consists  in  the  Pityrosporum 
Malassezii  (bottle-bacillus  of  Unna)  ;  and  the  skin  coccus  with 
grey  culture. 

Pityriasis  of  the  moustache  is  easily  improved,  but  difficult  to  cure 
on  account  of  rapid  recurrence.  It  becomes  spontaneously  attenu- 
ated in  the  course  of  time.  It  requires  local  hygiene  rather  than 
true  treatment,  such  as  daily  friction  with  Eau-de-Cologne  or  the 
following : — 

Alcohol  (60  per  cent)    ...        250  grammes  Bj 

Spirit  of  lavender 1 

Coal  Tar  (saponified)   •    •    •  J 

Bichloride    of    Mercury    .    .  30  centigrammes     gr.  ^ 

ECZEMA. 

Eczemas  limited  to  the  moustache,  like  these  of  the  beard  and  all 
hairy  regions,  generally  arise  from  a  previous  pityriasis.  They  pre- 
serve a  tendency  to  be  exclusively  limited  to  hairy  regions  and  their 
treatment  resembles  that  of  pityriasis  rather  than  that  of  acute 
eczema. 

These  eczemas,  with  their  serous  exudation,  often  insidiously 
replace  pityriasis,  with  its  fatty  scales.  They  are  sometimes,  how- 
ever, rather  acute  at  first.     The  serous  exudation  coagulates  on 


148  THE    REGION    OF   THE    MOUSTACHE. 

the  moustache,  as  a  greenish  brown  wax,  of  soft  and  fatty  con- 
sistence (seborrhoeic  eczema).  Under  the  crust  the  skin  is  red, 
and  secretes,  by  numerous  punctiform  erosions,  droplets  which 
form  the  crust. 

The  cause  of  this  eczema,  Hke  that  of  all  eczemas,  is  unknown.   In 
the  horny  epidermic  debris  is  found  the  flora  of  pityriasis.     Occa- 
sionally the  lesion  becomes 
impetiginous   and    assumes 
the  characters  and  flora  of 
|g^^^^^^^^  impetigo  (p.  7). 

Usually,  during  the 
whole  of  the  affection,  the 
crust  remains  amicrobial. 
This  affection  does  not 
therefore  appear  to  be  due 
to  a  secondary  infection  of 
pityriasis.  This  eczema  was 
formerly  classed  among  the 
"ichors"  of  lymphatic  sub- 
jects. It  is  more  often  seen 
in  adolescents,  blonde  or 
red,  with  soft  and  fatty  tis- 

Fie.  66.     Eczema    of    the    moustache    and  SUCS,    But    lymphatism,    Hkc 

^'^'"-  .    „  all  diasthetic  conditions,  is 

(A.    Fournier  s    patient.     St.    Louis    Hosp. 

Museum,  No.  946.)  Wanting   in   precise   defini- 

tion. 
Treatment.     Remove  the  crusts  with  oil  of  vaseline  and  apply 
weak  preparations  of  sulphur  or  oil  of  cade. 

(i)   Precipitated    Sulphur    ...  30  centigrammes  gr.  5 

Vaseline 30  grammes  5j 

(2)  Oil  of  Cade 2  grammes  5  f s 

Lanoline 30          "  3j 

These  may  be  increased  in  strength  later : — 

(3)  Oil  of  cade 5  to  15  grammes        3iii  to  ^j 

Lanoline 15    grammes  Sj 

(4)  Precipitated    Sulphur    ...   i  to     3  grammes  gt.  16  to  48 
Vaseline 30  grammes  5j 

The  patient  should  also  use  tar  or  sulphur  soap. 


THE    REGION   OF   THE    MOUSTACHE.  149 

ECZEMAS   NOT  LIMITED   TO   THE   MOUSTACHE. 


Eczemas  which  have  a  tendency  to  become  generaHsed  on  large 
surfaces  may  affect  the  region  of  the  moustache.  If  they  have  an 
evident  predilection  for  this  part  it  is  because  the  eczema  approaches 
the  type  described  above.  In  other  cases  its  localisation  on  the  mous- 
tache presents  nothing  special.  These  eczemas  will  be  studied  with 
the  other  chief  dermatoses  (p.  560). 

SYCOSIS. 

Sycosis  of  the  moustache  is  a  pustular  affection  presenting  a 
remarkable  tendency  to  chronicity  and  to  recurrence  after  apparent 

cure.     There  are  two  types: — 

In  the  first  the  sycosis  is  limited  ex- 
clusively to  the  region  of  the  mous- 
tache; in  the  second  it  is  common  to 
the  region  of  the  chin  and  cheeks  as 
well  as  the  moustache.  The  latter, 
which  is  very  different  to  the  first, 
will  be  studied  with  diseases  of  the 
beard  (p.  153). 

Sycosis  limited  to  the  Moustache. 
This  always  commences  under  one  or 
both  nostrils  and  often  remains  con- 
fined to  this  region.  It  arises  in  suc- 
cessive outbreaks  of  follicular  pus- 
tules of  the  type  of  impetigo  of  Bock- 
hart  (p.  183).  These  pustules  are 
greenish  yellow,  dome-shaped,  pierced 
by  a  hair  and  surrounded  by  a  red 
areola.  These  areolas  fuse  together,  and  the  pustules  develop  on  a 
slightly  raised  surface  of  inflammatory  oedema,  which  disappears 
so  much  the  more  slowly  as  the  pustules  are  reproduced  more  often. 
Sycosis  is  the  third  act  of  a  clinical  history  which  is  always  the 
same.  A  ciliary  blepharitis  begins  in  adolescence  and  a  rhinitis  fol- 
lows it;  and,  after  some  years,  the  nasal  mucus  inoculates  the  lip. 
Thus  sycosis  of  the  moustache  is  always  the  conseq-uence  of  a  "cold 
in  the  head."  chronic  or  recurrent.  The  microbe  of  the  pustules  is 
the  staphylococcus  aureus. 


Fig.  57.     Sub-nasal      Sycosis      con- 
secutive    to     chronic     anterior 
rhinitis.       (Besnier's     pa- 
tient.    St.    Louis   Hosp. 
Museum.    No.    813.) 


150  THE    REGION   OF   THE    MOUSTACHE. 

Sycosis  is  permanent,  or  at  any  rate  recurs  at  each  fresh  attack 
of  rhinitis.  Usually  it  only  becomes  permanent  after  several  recur- 
rences. When  once  established  there  is  no  spontaneous  tendency  to 
disappear  and  even  careful  treatment  succeeds  with  difficulty. 

Treatment.  The  blepharitis  and  rhinitis  should  first  be  treated 
by  irrigation  with  saline  solution  (8  in  looo),  or  isotonic  sea 
water  diluted  with  two  thirds  of  pure  water.  During  the  attacks 
care  should  be  taken  that  the  nasal  mucus  does  not  soil  the  lip. 
The  pustules  should  be  opened  every  morning  and  cauterised  with 
a  saturated  alcoholic  solution  of  boric  acid.  At  night  the  follow- 
ing is  applied  with  a  brush  : — 

Alcohol  60  per  cent 5  grammes       J  f s 

Precipitated  Sulphur i  "  gr.  48 

Distilled  water 5  "  3  f s 

If  this  lotion  is  not  tolerated,  sulphur  ointment  may  be  tried. 

Epilation  with  forceps  causes  disappearance  of  the  sycosis,  but 
this  re-appears  with  new  growth  of  the  hairs.  Nevertheless  it  is 
the  best  treatment  for  chronic  sycosis,  but  must  be  continued  for  a 
year  or  more  without  interruption.  The  X-rays,  especially  in 
cases  with  inflammatory  oedema,  have  given  good  results  in  the 
dose  of  2  or  3  units  H,  after  4  or  5  sittings  with  15  days  intervals, 
Xo  result  is  permanent  as  long  as  the  rhinitis  recurs. 

ALOPECIA    AREATA    OF    THE    MOUSTACHE. 

Alopecia  areata  is  seldom  limited  to  the  moustache.  When  this 
occurs  the  bald  place  often  affects,  on  the  left  side,  the  exact  situa- 
tion of  hare-lip.  It  resembles  alopecia  of  the  beard  in  its  very  slow 
evolution  and  difficulty  in  cure.  The  patch  is  more  often  completely 
bare  than  covered  with  down,  and  in  this  respect  it  resembles  alopecia 
of  the  scalp  more  than  that  of  the  beard  (p.  153). 

On  the  marginal  hairs  it  is  often  easy  to  observe  the  retrogressive 
changes  which  lead  to  their  atrophy  and  disappearance ;  i.e.,  diminu- 
tion of  pigment  and  of  diameter.  The  patch  is  often  cured  on  one 
side  while  extending  on  the  other.  Cure  is  announced  by  the  appear- 
ance of  scattered  white  hairs,  which  increase  in  number  and  grad- 
ually resume  their  pigmentation.  The  evolution  of  a  patch  of  alo- 
pecia on  the  moustache  generally  exceeds  a  year.  W^hen  it  occurs 
as  ^n  epiphenomenon   in   the  course  of  alopecia   areata  of  the 


THE    REGION   OF   THE   MOUSTACHE. 


151 


scalp  and  beard,  the  prognosis  depends  on  that  of  the  affection 
of  which  it  forms  a  part  (p.  219). 

The  etiology  of  alopecia  of  the  moustache  is  as  obscure  as  that  of 
alopecia  in  general.  Recently  Jacquet  has  shown  a  case  which  ap- 
peared to  be  connected  with  neuralgia  due  to  chronic  infection  of 
the  root  of  a  canine  tooth ;  but  many  similar  facts  are  necessary  to 
establish  such  a  theory. 

The  usual  treatment  by  revulsives  gives  only  moderate  results 
and  cannot  be  maintained  energetically  without  causing  disfigure- 
ment. Hence,  local  treatment  of  alopecia  areata  of  the  moustache 
is  almost  illusory.  Daily  frictions  may  be  given  with  glacial  acetic 
acid  in  alcohol  (2  per  cent)  or  lactic  acid  in  alcohol  (12  per  cent). 
The  irritation  caused  by  revulsive  treatment  may  be  partly  concealed 
by  applying  burnt  cork  to  the  patch. 


PIEDRA   NOSTRAS. 

This  is  a  rare  affection  which  I  have  only  seen  once  in  the  mous- 
tache.   It  is  said  to  be  more  rare  in  the  moustache  than  in  the  axillae 
and  pubes.     I  will  describe  the  case  which 
I  have  seen. 

In  an  extremely  thick  moustache  the 
affection  was  exactly  limited  to  the  sub- 
nasal  segment  on  each  side.  At  this  point 
every  second  or  third  hair  appeared  to  the 
naked  eye  to  have  been  dipped  in  paste, 
which  had  dried  on  it.  This  formed  a 
brownish  coating  which  was  very  resisting. 
When  the  hair  was  pulled  upon  it  did  not 
come  out,  but  broke  oft'  as  in  trichorrhexis 
nodosa,  and  the  split  extremity  was  curved 
and  twisted.  (Fig.  58.) 

It  appeared  to  me  that  a  physical  condi- 
tion favoured  the  development  of  the  para- 
site. The  hairs  of  the  nose  were  continued 
without  interruption  with  the  moustache,  so 
that  the  nasal  orifice  was  almost  completely 
obstructed.  Hence  the  moustache,  under 
the  nostrils,  was  continually  warm  and  moist,  and  infection  of  the 
hairs  appeared  to  arise  from  the  nostrils.     ]\Iicroscopic  examination 


Fig.  58.     Hair   of   mous- 
tache  affected    with 
Piedra   Nostras. 
(Preparation       by       Sa- 
bouraud.        Photo 
by    Noir^.) 


152  THE    REGION    OF   THE    MOUSTACHE. 

of  the  parasite  was  easily  made  by  the  methods  recommended  for 
ringworm,  i.e.,  immersion  and  warming  in  a  solution  of  liquor 
potassse  and  examination  without  staining.  The  hard  sheath  of  the 
hair  is  constituted  exclusively  by  the  parasite.  I  cannot  better  com- 
pare its  form  than  to  that  of  a  series  of  artichoke  heads  juxtaposed, 
which  are  separated  by  the  potash  and  which  consist  of  an  agglom- 
eration of  spores  on  a  highly  refractive  mycelium  arranged  in 
bunches.  The  parasite  is  easily  cultivated  on  all  media.  On  glu- 
cose-gelose  it  forms  a  round,  white  cultivation  which  becomes 
brown  during  growth.     Inoculation  has  not  yet  been  carried  out. 

Treatment.  Epilation  of  the  diseased  hairs  did  not  prevent  the 
neighboring  ones  becoming  affected  in  their  turn.  Simple  shaving, 
long  continued,  apparently  cured  the  affection.  In  a  similar  case  I 
should  prescribe  epilation  of  the  nasal  and  sub-nasal  hairs,  so  as  to 
maintain  an  open  space  under  the  nostril  and  alter  the  conditions  of 
warmth  and  moisture  which  the  parasite  appears  to  require.  A 
number  of  antiseptics  had  been  tried  without  success  by  the  patient, 
who  was  a  medical  man. 


The  region  of  the  beard. 


The   dermatological   affections   of  the   beard  are   numerous   and 
require  definite  order  in  their  explanation. 

I.    We  shall  first  treat  of  diseases  ivhich  cause 
complete   disappearance    of   the    hairs;    incomplete 


Alopecia    areata 


atrophy,    and    blanching J  g     •  •  •   • 

2.    IVe  shall  next  speak  of  diseases  of  the  hair^ 
itself,  and  first  of  all  of  a  great  increase  in  siser  Hyperplasia    . 
of  the  hair  which  constitutes  a  rare  disease  ... 

And   of   trichoptilosis   and   trichorrhexis   nodosa  \  ^  .  ,       , 

Y  i  nchorrhexis 


pi53 
P-  155 


dosa 

Dry 

tosis 


which  occur  in  the  beard  and  moustache J 

Next  of  trichophytosis  in  the  two  dry  forms  which 

it  affects,  si)nulating  ichthyosis  pilaris 

.    .    .  And    trichophytosis   of   the    type   identical 
with  trichophytosis  of  the  infant 

3.  We  shall  then  pass  on  to  the  study  of  diseases' 
of  the  follicle  Zi'ith  trichophytosis  of  the  sycosiform 
and   impetiginous   types 

.    .    .  And  with   trichophytosis  of  the  follicular-^ 

LKer 


Trichophy- 


P-  155 
p.  156 
p.  156 


type 


.  Trichophytic 
cosis  .   .   . 


ion  Celsi 


Sy 


P-  157 


P157 


p.  158 


Staphylococcic  Sy- 


Pityriasis 


N  on-trichophytotic    folliculitis    will    occupy    us^ 
next:  dry,  red  folliculitis;  pustular  folliculitis  and 
furuncle,   and   phlegmonous    or   cystic    folliculitis: 
morbid  forms  which  are  commonly   united  under 
the  term  df  non-parasitic  sycosis 

4.  Lastly  we  shall  treat  of  diseases  of  the  beard' 
affecting  more  especially  the  cutaneous  surface  it- 
self: at  first  the  pellicular  affections,  pityriasis  sim- 
plex   and    stcatoides: ^ 

.    .    .   The   dry    and   moist   eczema : Eczema 

And  the  lesions  of  true  impetigo Impetigo p.  164 

We  shall  mention  the  secondary  syphilitic  lesions' 
of  this  region  zi'hich  may  simulate  a  dry  eczema  or 
impetigo - 

And  we  shall  conclude  by  devoting  a  few  words~\ 

to   erythematous    and  tuberculous  lupus  situated  in  rLupus p.  164 

the  region  of  the  beard -^ 


P159 


p.  161 


p.  162 


Syphilis p-  164 


I.    ATROPHY    OF    THE    HAIR. 

Alopecia  Areata  of  the  Beard. 
Alopecia  of  the  beard  may  occur  alone  or  in  association  with 
alopecia  areata  of  the  scalp,  or  more  or  less  general  alopecia. 


154  ■  THE    REGION    OF   THE    BEARD. 

General  Alopecia.  This  has  the  character  and  the  prognosis  of 
severe  alopecia.  It  is  accompanied  by  a  shiny  condition  of  the  skin 
of  the  cheeks,  a  thinning  of  the  dermis  with  flaccidity  of  the  skin 
{"hypotoniis"  of  Jacquet)  and  a  total  disappearance  of  hair  on  the 
beard,  moustache,  eyebrows,  scalp  and  the  whole  body.  In  these 
cases,  which  we  shall  study  later  on  (p.  219),  local  treatment  is  of 
little  importance  and  general  treatment  is  rarely  successful  in  giving 
definite  or  rapid  results. 

After  months  or  years,  these  cases  may  end  in  complete  restora- 
tion of  atrophic  downy  hair;  or  there  may  be  transient  successive 
restorations  in  the  course  of  an  alopecia  of  indefinite  duration;  or 
there  may  be  no  return  of  hair  at  all.  The  face  remains  smooth  and 
permanently  wrinkled  for  10  or  15  years  or  more.  Complete  restora- 
tion of  hair,  in  these  cases,  is  very  rare. 

Common  Alopecia.  Benign  alopecia  of  the  beard  presents  a 
less  regular  type  than  that  of  the  scalp. 

There  is  one  form  with  small,  multiple,  transient  and  recurrent 
areas,  but  this  is  rare.  The  large  areas  of  alopecia  of  slow  evolution 
are  the  rule.  Their  situation  is  indifferent  and  their  form  irregular, 
with  a  rounded  outline.  As  a  rule  their  duration  is  proportional  to 
their  size,  and  for  the  same  size  an  alopecia  of  the  beard  is  two  or 
three  times  as  slow  in  evolution  as  one  on  the  scalp.  In  many  cases 
there  is  diminution  in  diameter  and  in  pigmentation,  but  no  disap- 
pearance of  the  hairs,  and  in  these  cases  the  affected  area  is  never 
smooth.  The  same  hair  remains  and  eventually  regains  its  colour 
and  diameter.  These  atrophic  hairs  may  be  mistaken  for  hairs  in 
process  of  restoration. 

Local  treatment  of  alopecia  of  the  beard  always  gives  less  favour- 
able results  than  that  of  similar  alopecia  of  the  scalp.  The  mildest 
case  lasts  for  12  or  18  months.  The  hairs  gradually  regain  their 
diameter  and  colour,  but  very  slowly,  and  one  patch  may  arise  while 
another  is  being  cured. 

The  etiology  of  this  alopecia  is  unknown,  or,  at  any  rate  disputed. 
In  my  opinion  the  theory  of  dental  origin  is  not  applicable  to  most 
cases  and  remains  to  be  proved  in  the  others.  The  existence  of  for- 
mer syphilis  is  too  often  observed  to  be  a  coincidence.  It  must  be 
borne  in  mind,  as  well  as  hereditary  syphilis,  in  all  cases  of  severe, 
chronic  recurrent  alopecia.  Even  in  these  cases  internal  treatment 
is  doubtful  and  requires  to  be  p-iven  svstematically.     For  local  and 


THE    REGION    OF    THE    BEARD.         *  155 

general  treatment  of  alopecia  of  the  beard  see  those  for  the  scalp 
(p.  219). 

The  skin  of  this  region  being  more  irritable  than  the  scalp,  milder 
doses  of  stimulating  applications  are  required  (glacial  acetic  acid  2 
per  cent  in  Hoffmann  s  liquor,  or  lactic  acid  in  alcohol  16  per  cent). 

In  many  cases  local  treatment  has  no  appreciable  effect  in  the  evo- 
lution of  the  disease. 

VITILIGO. 

Vitiligo  of  the  beard  differs  from  alopecia  areata  by  hyperpig- 
mentation  of  the  lesions  around  those  where  the  skin  is  depigmented. 
Cases  occur  where  differential  diagnosis  is  impossible  and  the  two 
diseases  may  be  of  the  same  origin. 

The  affected  areas  are  irregular,  asymmetrical  with  rounded  out- 
line, and  the  hairs,  which  may  be  diminished  in  number,  preserve 
their  size  bvit  lose  their  pigment.  They  are  silvery  white.  The  skin 
is  depigmented,  milky  white  and  sometimes  wrinkled  and  senile. 
Around  these  lesions  the  skin  is  normal  except  for  a  brown  hyperpig- 
mentation.  The  lesion  generally  extends  beyond  the  hairy  regions 
on  to  the  cheeks,  temples,  neck  and  scalp.  Certain  vitiligos  are  not 
accompanied  by  discoloration  of  the  hairs. 

Little  is  known  of  the  etiology  and  treatment  of  vitiligo  (p.  613). 
Topical  applications  have  hitherto  proved  futile,  but  there  is  no  rea- 
son why  high  frequency  and  radiotherapy  should  not  be  tried.  There 
is  often  a  history  of  former  syphilis  in  cases  of  vitiligo. 

II.   DISEASES   OF  THE   HAIR. 

Hyperplasia. 
I  refer  here  to  a  morbid  process  in  which  the  hairs,  principally 
on  the  cheeks,  assume,  without  any  known  cause,  unusual  forms  and 
dimensions.  The  hair  is  large  and  deformed,  and  sometimes  appears 
as  if  two  hairs  were  joined  together  laterally.  They  may  show 
various  forms  in  section  and  are  also  twisted  like  tree  stumps.  This 
condition  of  the  hair  is  not  accompanied  by  any  lesion  of  the  skin, 
except  occasionally  a  collar  of  follicular  desquamation.  There  is  no 
follicular  lesion  except  dilatation  necessary  to  allow  exit  of  the  hair, 
which  is  broken  spontaneously  at  a  distance  of  several  millimeters 
from  the  skin.     The  diseased  hairs  are  mingled  in  various  propor- 


156  '        THE    REGION    OF   THE    BEARD. 

tions  with  the  healthy  hair  and  often  occur  in  groups.     They  are 
covered  with  a  vitreous,  ahnost  glairy,  epithelial  sheath. 

The  etiology  of  these  rare  lesions  is  unknown  and  no  parasite  is 
found  on  microscopical  examination.  The  evolution  is  very  slow 
and  ends  neither  in  cure  nor  cicatrisation.  No  treatment  gives  any 
result,  but  I  should  be  inclined  to  advise  epilation  by  forceps,  as  was 
formerly  practised  in  favus  (p.  199). 

TRICHOPTILOSIS.    TRICHORRHEXIS    NODOSA. 

Here,  as  elsewhere,  trichorrhexis  causes  trichoptilosis.  These  are 
allied  affections,  although  trichoptilosis  may  occur  without  trichor- 
rhexis, on  beards  which  are  too  frequently  washed  with  hard  soap. 
These  two  affections,  the  termination  of  the  hair  in  the  form  of  a 
brush  or  feather  (trichoptilosis),  and  the  existence  of  fine  white 
nodosities  near  the  end  of  the  hair,  at  the  level  of  which  the  hair 
bends  and  breaks,  are  less  common  and  less  marked  in  the  beard 
than  in  the  moustache.  In  the  beard  they  are  most  frequent  on  the 
two  sides  of  the  chin  (see  p.  144  &  145). 

TRICHOPHYTOSIS    OF    THE    BEARD. 

Trichophytosis  of  the  beard  is  rare,  but  of  a  different  type  to 
that  of  the  scalp.  There  are  two  very  different  clinical  forms ;  one 
in  which  the  lesions  of  the  hair  are  accompanied  by  exudative  or 
suppurative  lesions  of  the  follicle  (p.  157),  and  one  in  which  there 
is  no  inflammatory  lesion  of  the  follicle ;  a  type  identical  with  the 
common  ringworm  of  children,  or  one  in  which  the  inflammatory 
lesion  is  reduced  to  a  dry  folliculitis  in  the  form  of  ichthyosis  pilaris. 

FORM    IDENTICAL    WITH    THE    COMMON    RINGWORM    OF 

CHILDREN. 

A  few  scurfy  circinate  lesions  of  the  skin  may  occur,  but  these 
may  be  absent.  The  lesions  of  the  hairs  are  slight,  but  visible  to 
the  naked  eye,  and  characteristic.  Black  hairs  may  be  observed,  in 
groups  or  singly,  larger  than  normal  hairs,  soft  and  twisted  in  th  j 
epidermis  in  the  form  of  a  corkscrew,  comma,  or  note  of  interroga- 


THE    REGION    OF    THE    BEARD.  157 

tion.  When  raised  with  a  needle  these  hairs  break  and  are  found 
to  be  filled  with  the  spores  of  a  fragile  trichophyton  forming  a  violet 
culture;  the  Trichophyton  inolaceiun,  a  species,  probably  of  animal 
origin.  The  two  cheeks  are  afifected,  often  successively,  in  twenty 
or  two  hundred  points,  each  including  from  2  to  6  diseased  hairs. 
The  evolution  of  this  trichophyton  is  always  chronic  and  lasts  for  2 
to  5  years  or  more.  Treatment  by  shaving  followed  by  applications 
of  tincture  of  iodine  (i  in  5)  gives  moderate  results,  or  cure  in  10 
to  18  months.  Treatment  by  X-rays  may  be  given  in  mild  doses 
every  week,  to  the  extent  of  three  applications  of  half  tint  B  of 
the  radiometer  X.  This  should  be  repeated  on  parts  which  have 
been  incompletely  depilated. 

DRY     TRICHOPHYTON     IN     THE     FORM     OF     ICHTHYOSIS 

PILARIS. 

A  few  lesions  occur  on  the  skin,  sometimes  similar  to  those  of 
the  preceding  species,  but  with  larger  circles.  The  diseased  hairs 
of  the  beard  are  broken  at  a  short  distance  from  the  skin.  They  are 
generally  numerous,  with  few  normal  hairs  between  them.  Around 
each  broken  hair  is  a  conical  follicular  projection,  i  to  2  millimeters 
in  height,  crateriform  when  the  hair  breaks  oflf  deeply,  or  surmounted 
by  the  hair  broken  a  millimeter  beyond  it.  The  hair  is  large,  white 
and  chalky,  like  the  follicular  cone  from  which  it  emerges,  and  is 
broken  by  epilation.  Microscopical  examination  shows  large  roimd 
spores,  arranged  in  rows  and  surrounded  by  a  fine  mycelial  network 
with  regular  septa,  external  to  the  hair.  It  forms  a  white,  downy, 
cup  shaped  culture  presenting  on  the  upper  surface  a  large  black 
spot.  The  culture  is  flattened  longitudinally  and  the  surface  assumes 
a  red  colour.  {Trichophyton  rosaccuni:  probably  of  avian  origin 
in  many  cases,  and  experimentally  proved  in  several).  The  treat- 
ment is  the  same  as  for  the  preceding  species. 

■     .    ,.1,  f.M,!)' 

III.    DISEASES    OF   THE   FOLLICLES. 

Trichophytosis  zvith   Follicular  reaction. 

We  shall  now  study  diseases  of  the  beard  accompanied  by  fol- 
licular lesions.    Several  ringworms  are  included  in  this  class. 


158 


THE    REGION    OF   THE    BEARD. 


Sycosiform  and  Impetiginous  Trichophytosis.  The  symptoms 
of  this  form  vary  in  different  cases.  Sometimes  the  lesions  form 
moist,  red,  impetiginous  patches  of  epidermatitis,  in  the  region  of 
which  trichophytic  hairs  are  scattered  among  heahhy  ones.  At 
other  times  the  lesions  form  folliculitis,  not  agglomerated,  but  scat- 
tered, resembling  those  of  pustular  or  indurated  acne.     Sometimes 

they  project  from  the  skin  in  a  semi- 
fungating  form,  formerly  called  syco- 
sis. 

The  diseased  broken  hairs  are  few 
and  scattered,  and  project  for  one  to 
two  millimeters  from  a  grey  epidermic 
collar,  which  often  adheres  to  them. 
The  parasite,  having  a  more  resisting 
mycelium  than  the  preceding  species, 
is  formed  by  rows  of  large  spores 
(endo-ectothrix).  The  culture  is  pow- 
dery, yellow  and  very  analogous  to 
that  of  the  common  ringworm  of  chil- 
dren (T.  cratcriforme).  These  are 
said  to  be  identical,  but  the  question 
is  not  settled.  (T.  Haviim.)  The  treat- 
ment is  the  same  as  for  the  two  pre- 
ceding species,  and  the  greater  the  in- 
flammatory reaction,  the  better  the  prognosis. 

Trichophytosis  Known  as  Kerion  Celsi. — This  forms  one,  two 
or  three  red  projections  on  the  skin,  more  or  less  circular  and  riddled 
with  pustules  and  scabs  in  all  stages.  Pus  may  be  expressed  from 
all  the  hair  follicles.  The  objective  symptoms  are  very  analogous 
to  anthrax,  but  the  functional  symptoms,  especially  pain,  are  much 
less  marked. 

Epilation  of  the  surface  is  painless,  and  all  the  hairs  are  sponta- 
neously detached  in  whole.  IMost  of  the  hairs  are  not  trichophytic, 
excepting  the  small  downy  hairs  around  the  lesion.  When  the  lesion 
is  cleansed  it  is  riddled  with  holes  like  a  sieve.  Microscopical  ex- 
amination should  be  made  of  the  pus  (sporulating  mycelium),  rather 
than  of  the  diseased  hairs,  which  are  always  difficult  to  find  {endo- 
ectothrix  with  fine  spores  in  chains).  Culture  is  always  easy  and 
pure  when  an  unbroken  pustule  is  taken.    {Trichophyton  gypseum 


Figr.  59.     Trichophyton     of    equine 

origin.      Kfirion  de   Celse. 

(Besnler's      patient.        St.      Louis 

Hosp.     Museum,     No.     1733.) 


THE  REGION  OF  THE  BEARD- 


159 


pyogenes).    This  trichophyton  has  been  experimentally  shown  to  be 

of  equine  origin,  and  the  occu- 
pation of  the  patient  (groom, 
coachman,  veterinary  sur- 
geon, knacker,  harness  maker) 
often  indicates,  but  not  al- 
ways, the  origin  of  the  infec- 
tion. 

Kerion  Celsi  may  occur 
apart  from  the  beard,  on  the 
neck,  wrists  or  scalp ;  both  in 
children  and  adults. 

Treatment  consists  in  care- 
ful cleansing,  removal  of 
scabs  and  dead  hairs,  painting 
with  tincture  of  iodine  (i  in 
lo)  and  moist  dressings.  The 
cure  is  rapid,  provided  the 
applications  are  not  too 
strong. 

Rare  forms  of  trichophy- 
tosis.— Other  mycoses  of  the 
same  group  may  be  seen  in 
the  same  region,  with 
slightly  different  characters, 
and  varying  in  epidermic  lesions ;  large  or  small  circles,  vesico-pus- 
tular  or  squamous,  more  or  less  inflammatory,  etc.  Bodin  has  ob- 
served in  the  beard  a  Microspormn  Audouini  of  equine  origin;  the 
lesions  in  the  beard  being  identical  in  form  with  those  of  the  Micro- 
sporum  of  the  child's  scalp  (p.  189). 


Fig.  60.     Trichophytosis    In    the    form    of 

agminated     follicles.       Kerion     Celsi. 

(Quinquaud's    patient.       St.     Louis    Hosp. 

Museum,     No.    1679.) 


STAPHYLOCOCCIC   SYCOSIS. 


This  disease  is  homologous  in  the  adult  beard  with  the  impetigo 
of  Bockhart  in  the  child  (p.  183).     It  is  a  pustular  folliculitis  occur- 


i6o 


THE    REGION    OF    THE    BEARD. 


ring  in  patches,  of  chronic  evolution,  paroxysmal,  and  recurring 
after  cure.    The  microbe  is  always  the  staphylococcus  aureus.    The 

causes  which  favour  its  implantation 
and  growth  are  unknown.  A  pus- 
tular path  formed  of  follicular  pus- 
tules appears  on  one  cheek  and 
grows  by  the  addition  of  new  pus- 
tules. The  patch  is  irregular,  and 
the  symptoms  very  marked ;  pain, 
heat  and  smarting.  The  pustules  cre- 
ate a  zone  of  inflammatory  oedema 
which  fuses  with  that  of  the  neigh- 
bouring pustules. 

On  this  red  placard,  which  persists 
because  the  follicles  remain  infected 
when  once  attacked,  new  pustules 
form  continually.  Sometimes  similar 
lesions  spring  up  at  a  distance.  In 
this  way  a  chronic  dermatitis  is  con- 
stituted which  lasts  for  months  or 
years.  In  certain  cases  a  vesicular, 
eczematous  element  is  joined  to  the  pustular;  with  amber 
coloured  crusts,  very  pruriginous  and  slightly  moist.  This  lesion 
has  been  attributed  to  all  the  indefinite  diasthetic  conditions, 
such  as  lymphatism,  arthritism,  etc.,  but  nothing  definite  is 
known  of  its  ultimate  causes. 

Treatment  is  empirical,  varying  in  different  cases  which  are  diffi- 
cult to  class  according  to  their  indications.  When  inflammatory 
symptoms  are  intense,  local  antiphlogistics  are  indicated ;  cataplasms 
of  starch  meal  made  hot  and  applied  cold ;  moist  dressings  with  Van 
Swieten's  solution  (one  part  of  perchloride  of  mercury  in  loo  parts 
of  alcohol  and  900  of  water).  Epilation  is  only  temporary  in  its 
results,  as  the  lesion  recurs  in  the  new  hairs ;  but  it  eventually  gives 
good  results,  in  chronic  cases.  Antiseptic  and  astringent  applica- 
tions such  as  saturated  boric  alcohol,  nitrate  of  silver  (i  in  15)  are 
usually  badly  tolerated ;  also  sulphur  applications,  except  in  very 
chronic  cases. 

The  X-rays  in  half  doses  (half  tint  B  of  the  radiometer  X),  ap- 
plied every  week  for  a  month  or  6  weeks,  often  give  good  results, 
and  not  only  on  account  of  the  local  alopecia  which  is  caused. 


Fig.  61.     Non-trichophytic    sycosis 

(Fournier's   patient.      St.    Louis 

Hosp.    Museum,    No.    985.) 


THE    REGION    OF    THE    BEARD.  i6i 

Dry,  red  folliculitis  of  the  Beard.  This  process  is  not  very  com- 
mon, but  chronic  and  difficult  to  treat.  A  series  of  disseminated  red 
follicular  points  appear  on  the  cheeks,  with  diminution  in  the  num- 
ber of  hairs  by  follicular  sclerosis,  forming  almost  invisible  cicatrices. 
This  lesion  resembles  symptomatically  the  post-seborrhoeic  sclerosis 
of  the  hair  follicles  of  the  scalp  (p.  238));  the  psuedo-alopecia 
areata  of  Brocq  (p.  224)  and  of  Acne  decalvans  )p.  166). 

Furuncle.  This  rarely  develops  in  its  usual  form  in  the  beard, 
but  is  generally  replaced  by  a  follicular  pustule,  of  sub  acute  quasi- 
acniform  evolution. 

Epilation  or  cauterisation  with  the  galvano-cautery,  and  applica- 
tions of  saturated  boric  alcohol,  constitute  the  treatment.  Reinocu- 
lation  in  the  adjacent  parts  must  be  anticipated  and  aborted  by  the 
same  methods. 

Phlegmonous  cystic  acne  of  the  maxillary  or  sub-maxillary  re- 
gion occurs  in  the  form  of  pustules  of  the  same  nature  as  those  just 
described.  They  arise,  in  the  adolescent,  in  the  course  of  a  more  or 
less  general  polymorphous  acne.  They  give  rise  to  cold  cystic  ab- 
scesses ;  very  disfiguring,  tenacious  and  recurrent,  and  often  accom- 
panying similar  lesions  on  the  neck  (p.  166). 

They  are  treated  in  the  same  way  as  phlegmonous  sycosis  of  the 
neck,  of  which  they  are  the  homologues.  Excellent  results  are 
obtained  by  the  galvano-cautery,  and  by  alternate  cauterisations 
with  crayons  of  nitrate  of  silver  and  metallic  zinc.  These  should  be 
freely  manipulated  in  the  diverticula  of  the  abscesses.  Sulphur 
waters  are  recommended  both  internally  and  externally  in  all  forms 
of  acne,  especially  in  this  form. 


IV.     DISEASES    OF    THE    CUTANEOUS    SURFACE: 

Pityriasis  Simplex. 

Pityriasis  Simplex  is  seen  in  the  beards  of  many  men,  who  are 
unaware  of  it  owing  to  the  squames  being  very  fine.  This  affection, 
which  occurs  chiefly  in  the  sub-mental  region,  is  only  apparent  to 
the  patient  by  slight  itching,  exaggerated  by  neglect  of  toilet,  indi- 
gestion or  a  sleepless  night ;  and  by  a  fine  powder  removed  by  fric- 
tion. 

II 


l62  THE    REGION    OF    THE    BEARD. 

Treatment  consists  in  daily  friction  with  a  solution  of  tincture  of 
iodine  in  Eau  de  Cologne  (30  per  cent)  ;  or  saponified  coal  tar  (15 
per  cent). 

Pityriasis  Steatoides,  with  larger,  more  fatty  and  yellow  squames 
and  situated  on  a  skin  redder  than  normal,  is  less  common  than  the 
preceding  form,  but  more  apparent.  It  is  more  pruriginous  and 
more  dirty,  the  scales  falling  incessantly  on  the  clothes.  ^loreover, 
it  is  accompanied  by  similar  lesions  of  the  scalp,  moustache  and 
chest. 

It  is  a  true  pityriasis,  in  the  bacteriological  sense ;  that  is.  a  des- 
quamative epidermatitis  due  to  the  presence  of  the  spore  of  Malassez 
{Pityrospornm  Malassedi,  or  bottle  bacillus  of  Unna). 

The  treatment  of  this  affection  varies  according  to  the  intensity 
of  the  process.  Benign  cases  are  treated  as  pityriasis  simplex;  more 
severe  cases  require  stronger  applications  of  tar : — 

(i)   Acetone 20  grammes  *j 

Oil  of  Cade i  to     2  grammes    gr.  24-48 

(2)   Oil    of   Cade 5  grammes  5  i  f s 

Lanoline 30  grammes  oj 

These  are  washed  off  in  the  morning  with  tar  soap. 

More  severe  cases  require  stronger  applications : — 

Oil  of  Cade 10  grammes       5  fs 

Lanoline     . 20  "  5J 

Yellow  oxide   of   Mercury  . 

Oil  of  birch 

Ichthyol 

Resorcine 


-  aa     I  gramme      gr.  16 


When  the  pityriasis  has  disappeared,  continue  to  use  weak  alco- 
holic tar  lotions  daily,  to  prevent  recurrence.  (See  formula  on 
p.  147). 

ECZEMA    (DRY,  SQUAMOUS,    FATTY    AND    NUMMULAR). 

When  the  preceding  cases  are  allowed  to  develop,  they  often  end 
in  the  formation  of  fatty,  squamous,  almost  exudative  lesions,  which, 
extending  beyond  the  hairy  regions  from  which  they  proceed,  invade 
more  or  less  the  smooth  skin.  These  lesions  are  generally  round 
and  nummular  and  may  become  generalised  on  the  whole  body  in 


THE    REGION    OF    THE    BEARD.  163 

a  more  or  less  complete  and  regular  form,  maintaining  a  preference 
for  hairy  regions. 

These  lesions  must  be  understood  to  consist  in  amicrobial  ecze- 
matisation  of  a  microbial  pityriasis.  There  is  always  a  clinical  chain 
between  these  cases  and  psoriasis,  and  this  group  (recently  called 
Seborrhoeic  Eczema  of  Unna)  is  often  confounded  clinically  with 
true  psoriasis,  recognized  histologically  by  the  peculiar  and  specific 
structure  of  the  psoriasic  squame. 

The  treatment  is  that  of  steatoid  pityriasis.  IMild  preparations 
are  commenced  with  : — 

Oxide  of  zinc 7  grammes     3ii 

Oil  of  Cade ,  .    .  5  "  3i.fs 

Lanoline 25  "  jj 

Afterwards  more  active  preparations  of  the  type  of  the  last  oint- 
ment indicated  are  used,  which  quickly  reduce  the  lesions  as  soon 
as  they  are  tolerated  by  the  skin. 

EXUDATIVE   ECZEMA. 

Weeping  eczema  is  rare  in  the  region  of  the  beard,  apart  from 
artificial  eczema,  which  has  been  studied  elsewhere.     Impetigo  is 


Fig.  62.     Impetigo  contagiosa  of  the  beard.  (Sabouraud's    patient.     Photo,    by    Noire.) 

often  mistaken  for  it.     When  impetiginous  eczema  occurs  on  the 
face  in  young  men  it  is  generally  before  the  growth  of  the  beard 


164 


THE    REGION    OF    THE    BEARD. 


and  has  no  special  character.     It  is  situated  on  the  cheek  bones 
rather  than  on  the  maxillary  regions. 

IMPETIGO. 

Impetigo  of  the  beard  is  not  uncommon  in  blonde  adolescents  and 
occurs  in  the  form  of  disseminated  crusts  with  rounded  outlines, 
thinner  and  more  papyraceous  than  in  the  child. 

Under  this  friable  crust  the  skin  is  red  and  deprived  of  the  horny 
epidermis  and  exudes  a  drop  of  clear  serum.  The  diagnosis,  prog- 
nosis and  treatment  present  no  special  features  (p.  7). 


\ 


SECONDARY   SYPHILIS. 

In  the  course  of  secondary  syphilis,  exulcerated  papular  syphilides 
(the  so-called  cutaneous  mucous  patches)  may  occur  in  the  region 
of  the  beard  and  may  be  mistaken  for  impetigo. 

The  crust  is  less  hard,  more  regular  and  flatter.     Underneath 

the  crust  is  a  round  projecting 
papule,  exulcerated  on  the  surface 
but  not  exudative.  All  these  char- 
acters differ  from  impetigo. 
Moreover,  red  non-exulcerated 
papules  are  seen  on  other  parts  of 
the  face  and  body.  There  is  no 
special  treatment  of  these  syphi- 
lides and  the  internal  treatment  is 
that  of  secondary  syphilis. 

LUPUS. 


*^"*^; 


Lupus  Erythematosus  of  the 
beard  is  an  accidental  localisation 
and  presents  all  the  usual  charac- 
teristics, and  causes  destruction  of 
the  beard  on  its  surface. 

Tuberculous  Lupus  is  often 
situated  in  the  sub-mental  region.  It  maintains  the  usual  charac- 
ters of  the  first  stage  of  lupus  and  rarely  becomes  fungous  or  ulcera- 
tive. 


fig.  63.     Vegetating    papular    Syphil- 
ides.     (Guibout's    patient.       St. 
Louis    Hosp.    Museum, 
No.    907.) 


THE  NAPE  OF  THE   NECK. 

The  nape  of  the  neck  presents  four  chief  morbid  types. 

It  is  the  seat  par  excellence   of  pediculous  iln-^  Pediculous        i  m- 
t^tigo j"     petigo p.  i6s 

It  is  a  region  which  presents  frequent  pustularl 
eruptions  of  sub-acute  evolution:  pustular,  sycosi-y Acne  pustulosa  .  .  p.  i66 
form  and  keloid  acne J 

.    .    .    Gr,    of    acute    evolution:    furuncle;    pcri-^ 
furuncular  abscess;  carbuncle ^ruruncle p.  i6g 

It  is  a  region  where  diverse  types  of  trichophyton-^ 
of  animal  origin  are  often  observed "  .     ^Trichophytosis    .  .  p.  170 

Lastly,  it  is  a  region  in  which  chronic,  iniiltrated,~\ 
pruriginous  patches  are  seen  to  develop,  which  were  L ■Lichenoid      K  c  ze- 
formerly  known  as  lichen  circumscriptus J      matisatiun     .    .   p.  172 


PEDICULOSIS.     PEDICULOUS    IMPETIGO. 

Pediculosis  and  the  irritative  lesions  which  it  causes  occur  at 
all  ages  and  in  both  sexes,  but  most  commonly  in  adolescence 
and  in  women.  The  long  hairs  favour  the  multiplication  of  para- 
sites, especially  when  a  young  girl  wears  a  low  chignon,  or  plaits. 
These  conditions  localise  the  maximum  point  of  pediculous 
lesions  to  the  sub-occipital  fossa  . 

On  raising  the  hairs  a  region  with  a  repulsive  aspect  is  disclosed. 
At  first  there  appears  a  mass  of  crusts,  adherent  to  the  hairs  and 
resembling  coagulated  melted  sugar.  On  separating  the  hairs,  the 
crusts  are  broken  up,  each  hair  retaining  a  part  of  them  {impetigo 
granulata  of  Alibcrt) .  Among  the  crusts  and  on  the  moist  skin  the 
lice  may  be  seen  moving  among  the  hairs.  On  closer  examination 
innumerable  eggs  are  seen  glued  to  the  hairs.  They  are  the  size  of  a 
pin's  head,  grey  and  shining  (Fig.  70). 

The  impetiginous  lesions  decrease  in  number  the  further  from  the 
neck  one  examines.  These  lesions  occur  in  two  distinct  forms; 
phlyctenular  impetigo  (p.  7)  and  pustular  folliculitis,  or  impetigo 
of  Bockhart  (p.  183).  They  are  accompanied  by  painful  adenitis  of 
the  sub-occipital  glands.    The  number  of  lice  and  nits  also  decreases 


i66  THE  NAPE  OF  THE  NECK. 

further  away  from  the  neck.  The  louse  of  this  region  of  the  neck 
is  the  head  louse  (p.  i8i). 

The  treatment  of  pediculosis  of  the  neck  does  not  differ  from  that 
of  the  scalp,  but  may  present  several  particular  indications : — 

(i)  The  abundance  of  crusts  may  lead  to  cutting  the  hair  over 
the  oval  space,  several  centimeters  in  diameter.  But,  as  a  matter  of 
fact,  this  is  not  absolutely  necessary  in  any  disease  of  the  scalp. 

(2)  A  large  quantity  of  vaseline  may  be  applied  locally  and  the 
softened  crusts  removed  the  next  day  with  the  dead  parasites,  by 
means  of  a  comb. 

(3)  The  skin  may  be  treated  with  Oxide  of  zinc  ointment,  or  the 
following  lotion,  to  cicatrise  the  epidermis : — 

Distilled  water 300  grammes  5j 

Sulphate  of  zinc 2  "  gr.  3 

Sulphate   of   copper i  "  gr.  ij^ 

(4)  It  only  remains  to  destroy  the  nits.  The  hair  being  cleansed 
of  fat,  it  is  sufficient  to  soak  it  for  several  hours  in  warm  vinegar. 
By  this  means  the  nits  are  half  dissolved  and  may  be  detached  from 
the  hairs  by  a  fine  comb.  All  should  be  well,  in  the  most  difficult 
cases,  in  less  than  a  week. 


ACNE    (PUSTULAR,   SYCOSIFORM,   CICATRICIAL,   CHELOID). 

Seborrhoea,  acne  and  its  complications  assume,  in  the  region  of 
the  neck,  a  peculiar  appearance. 

1.  As  soon  as  seborrhoea  appears  in  the  centre  of  the  face  the 
seborrhceic  infection  of  the  neck  has  taken  place.  For  some  time  it 
only  manifests  itself  by  black  follicular  spots,  which  are  not  comedos. 
When  the  follicles  are  emptied  by  forceps,  they  are  seen  to  contain 
from  10  to  20  downy  hairs  agglutinated  in  a  black  mass  which  is 
micro-bacillary  (p.  13). 

2.  After  this  first  stage,  in  persons  between  17  and  25  with  fat 
necks,  occurs  disseminated  pustular  acne  which,  according  to  the 
intensity  of  the  inflammatory  phenomena,  maintains  the  characters 
of  ordinary  pustular  acne  or  assumes  more  and  more  those  of  local 
recurring  furunculosis. 

3.  Even  with  the  most  marked  functional  phenomena,  pustular 
acne,  when  its  elements  become  numerous  and  coherent,  constitutes 


THE    NAPE    OF    THE    NECK.  167 

sycosis  of  the  neck,  resembling  in  all  its  objective  and  developmental 
characters  sycosis  of  the  beard. 

The  whole  nape,  or  the  whole  of  a  horizontal  zone,  is  riddled  with 
follicular  pustules  situated  on  a  cushion  ot  inflammatory  oedema. 
This  affection,  which  is  of  slow  progress,  and  interrupted  by  acute 
outbreaks,  is  extremely  disfiguring. 


Figr.  64.     Sycosiform    pustular   acne    of   the   neck. 
(Befanier's    patient.     St.    Louis    Hosp.    Museum,    No.    1144.) 

4.  Sycosis  of  the  nape  often  occurs  in  the  form  of  a  narrow  hori- 
zontal band  which  cicatrises  below,  while  increasing  above  by  the 
formation  of  new  pustules  (Fig.  64). 

In  its  fully  developed  state  this  special  form  of  sycosis  is  often 
accompanied  by  a  horizontal  cheloid  band,  like  the  line  of  pustules  by 
which  it  is  bordered.  This  cheloid,  consisting  mainly  of  inflamma- 
tory tissue  rather  than  fibrous  tissue,  causes  a  more  or  less  deformed 
projection,  above  and  below  which  the  hairs  emerge  in  bunches. 

5.  Finally,  this  cheloid  acne  of  the  neck,  in  rare  cases,  extends  on 
to  the  hairy  scalp  and  slowly  forms,  on  the  occipital  segment,  a  bald 
fibrous  patch  bordered  by  a  circumferential  cheloid,  riddled  with 
recurrent  pustules  (Fig.  65).  This  lesion  is  connected  with  the 
lesion  of  the  neck,  of  which  it  is  only  an  abnormal  development. 


i68  THE  NAPE  OF  THE  NECK. 

These  sycosiform,  pustular,  cheloid  lesions  remain  for  years  and 
slowly  decrease.  I  have  never  seen  cheloids  persist  after  disappear- 
ance of  the  pustules.    They  become  gradually  attenuated. 


Fig.  65.     Cheloid    pustular   acne:    acne    decalvans. 
(Danlos'  patient.     St.   Louis  Hosp.   Museum,   No.   1979.) 


The  treatment  of  all  these  lesions  is  comprised  in  three  formulae : 
avoid  injury;  treat  the  recent  and  active  lesions  by  sulphur,  and  the 
chronic  lesions  by  epilation. 

1.  These  lesions  are  often  kept  up  by  the  rubbing  of  stiff  collars 
or  rough  coats.    These  causes  must  be  suppressed. 

2.  The  best  local  application  is  Vidal's  Sulphur  lotion : — 

Precipitated    Sulphur    .    . 


aa     10  grammes     aa  gr.  lo 
Alcohol  90  per  cent 

Distilled    water 1 

^   aa     50  aa      3  f s 

Rose  water J 

This  is  applied  at  night  by  a  brush.  If  the  skin  is  delicate  the 
region  should  be  surrounded  by  a  border  of  zinc  paste  to  avoid  dis- 
semination of  the  sulphur  powder. 

3.  When  there  is  conglomerated  folliculitis  (sycosis),  and  especi- 
ally in  cheloid  acne,  epilation  is  necessary  and  should  be  carefully 
repeated  several  times.     It  should  be  performed  in  the  same  way  as 


THE    NAPE    OF   THE   NECK. 


169 


for  favus  (p.  199).  Local  applications  are  the  same  as  indicated 
above.  If  the  cheloids  persist,  they  should  be  treated  by  linear 
quadrilateral  scarification,  but  this  is  rarely  necessary  here. 

General  treatment,  as  in  many  cutaneous  affections,  is  based  on 
general  examination  of  the  subject,  and  there  is  no  precise  line  of 
action.     The  patient  is  usually  fat  and  his  skin  becomes  easily  con- 


Fig.  66.     Pustular,    sycosiform    cheloid    acne. 
(A.   Fournier's   patient.     St.    Louis   Hosp.    Museum,    No.    2059.) 

g-ested.  In  such  a  case  overfeeding  should  be  avoided  and  the  in- 
testinal evacuations  and  diuresis  assisted.  A  vegetarian  rather  than 
a  meat  diet  is  indicated.  These  indications,  however,  do  not  apply 
to  all  cases. 


FURUNCULOSIS. 


PERIFURUNCULAR     ACNE. 
CARBUNCLE. 


PHLEGMON. 


Furuncuiosis  of  the  nape  of  the  neck  is  closely  allied  to  acne  of 
the  same  region.  It  arises  under  the  same  local  and  general  condi- 
tions and  is  only  distinguished  by  the  greater  intensity  of  the  func- 
tional symptoms  and  the  formation  of  a  core  in  lesions  which  are  at 
first  pvistular.  like  acne.    After  the  furuncle,  a  perifuruncular  abscess 


170  THE  NAPE  OF  THE  NECK. 

commonly  arises.  When  these  lesions  are  multiple  from  the  first,  a 
phleg-mon  of  the  neck  may  develop  with  more  than  twenty  openings : 
this  is  one  of  the  types  of  carbuncle  of  the  neck.  More  often  there 
are  only  one  or  two  lesions  which  develop  together  at  some  distance 
apart;  but  when  these  diminish  and  disappear,  others  are  formed; 
and  this  may  continue  for  months.  Sometimes  furunculosis  of  the 
nape  is  only  an  epiphenomenon  in  the  course  of  general  furunculosis ; 
but  this  is  rare. 

Carbuncle  of  the  nape  of  the  neck,  as  elsewhere,  is  only  a  furuncle 
which  is  multiple  from  the  first  and  of  excentric  development.  The 
nape  of  the  neck  is  its  seat  of  predilection  and  the  local  furunculosis 
which  we  have  just  described  is  an  almost  necessary  condition  for 
its  formation.  When  well  treated  from  the  first  it  is  generally  ar- 
rested without  much  trouble ;  later  on  its  treatment  belongs  to  the 
surgeon  and  is  beyond  the  scope  of  this  work.  The  general  treat- 
ment of  furtmculosis  of  the  nape  of  the  neck  is  the  same  as  for  fur- 
unculosis in  general  and  depends  upon  the  condition  of  the  patient 
(phosphaturia,  diabetes,  emaciation,  obesity,  etc.). 

The  treatment  of  furunculosis  is  the  same  as  that  for  acne.  Noth- 
ing arrests  furunculosis  of  the  nape  so  well  as  sulphur  lotion,  com- 
bined with  epilation  of  the  central  hair  of  the  lesion.  When  local 
inflammation  and  pain  are  severe  a  poultice  of  potato  starch,  made 
hot  and  applied  cold,  and  sprinkled  with  camphorated  alcohol  may 
be  added. 

Lastly,  surgical  treatment  of  this  affection  takes  an  important 
place  as  soon  as  the  lesions  become  numerous  or  the  symptoms  pain- 
ful. Each  furuncle  or  abscess  should  be  opened  deeply  with  the 
galvano-cautery,  and  the  appearance  of  new  pustules  carefully 
watched  for.  This  is  still  more  necessary  when  perifuruncular  ab- 
scesses arise,  or  when  the  furuncles  become  agglomerated  and  assume 
carbuncular  evolution.  In  this  case  the  galvano-cautery,  when  care- 
fully used,  renders  great  service.  When  there  has  been  necrosis  and 
slow  cicatrisation,  the  following  ointment  is  useful,  as  in  all  atonic 
ulcers : — 

Sub-carbonate  of  iron i   gramme     gr.  12 

Vaseline 40  "  5j 

TRICHOPHYTOSIS. 

The  nape  of  the  neck  is  one  of  the  seats  of  predilection  of  animal 
trichophytons   (p.   156).     Sometimes  there  is  direct  inoculation  by 


THE    NAPE    OF   THE    NECK. 


171 


carrying  a  dead  or  diseased  animal  on  the  neck ;  at  other  times  the 
inoculation  is  indirect,  through  irritation  caused  by  clothing.  Ani- 
mal ringworms  may  be  recognised  by  their  anomaly  of  form  and  evo- 
lution.    In  this  region  three  forms  are  usually  observed. 

The  most  frequent  appears  to  be  Kcrion  of  Celsus  (p.  158),  which 
preserves  here  the  same  characters  as  in  the  beard.  It  forms  a  flat 
red  suppurating  patch  and  is  of  equine  origin. 

Secondly,  there  is  a  squamous  ringworm,  characterised  by  a  red 
serpiginous  border,  benign  evolution  and  very  numerous  patches, 
which  appears  to  originate  in  the  calf  or  the  goat  (Fig.  67). 


Fig.   67.      Trichophytosis   of   Animal   origin    (j^oat). 
(Du    Castel's    patient.      St.    Louis    Hosp.      Museum,    No.    1893.) 


Thirdly,  there  is  a  poly-micro-circinate  ringworm  of  extensive 
development  in  the  form  of  a  band  or  collar.  These  lesions  are  very 
chronic,  lasting  for  3  to  lo  years  and  appear  to  be  derived  from  the 
dog.  They  are  characterised  by  a  thin  red  punctate  border  of  vesico- 
pustules,  excoriated  by  scratching. 

The  two  last  species  are  cured  in  a  few  days  by  applications  of 
tincture  of  iodine,  i  in  3  or  i  in  4  in  alcohol.    I  have  mentioned  the 


1572  THE    NAPE    OE   THE    NecK. 

treatment   of   kerion   with   ringworm   of   the   beard   and   scalp    (p. 
159  &  196). 

LICHENOID  ECZEMATISATION. 

Chronic  patches  of  Hchenoid  eczematisation  may  occur  in  young- 
persons  as  the  local  result  of  an  impetiginous  eczema,  with  dimin- 
ished acidity  of  the  urine  and  albumen  (p.  12)  ;  but  more  often  in 
the  adult  or  among  neurotic  persons. 

The  lesion  is  small,  median,  lateral  or  bilateral,  red,  slightly  moist, 
very  pruriginous,  not  crusted,  slightly  squamous,  of  slow  evolution 
and  growth,  up  to  5  to  8  centimeters  in  diameter. 

It  is  resistant  to  treatment  and  the  hypodermis  beneath  it  becomes 
thickened.  Its  wrinkled  surface,  divided  by  nearly  regular  quad- 
rilateral furrows,  has  the  shining  and  parquetted  appearance  char- 
acteristic of  the  clinical  syndrome  designated  lichenisation  (p.  547). 
Pruritus  is  intense  and  paroxysmal,  especially  at  night. 

This  dermatitis  is  rarely  exudative  and  very  chronic,  and  con- 
stitutes the  lichen  circumscriptus  of  the  older  French  authors.  It 
may  occur  in  a  single  place,  or  may  form  a  particular  localisation  of 
a  lichenised  prurigo  of  various  situations  (p.  543). 

General  treatment  depends  on  the  condition  of  the  patient,  and  is 
not  the  same  in  every  case.  Local  treatment  gives  only  mediocre 
results,  but  in  benign  cases  anti-pruriginous  ointments  may  be 
used : — 

Glycerole  of  Starch 40  grammes  5J 

Resorcine 1 

Tartaric  acid [■a.a     40  centigrammes     gr.  5 

Menthol J 

In  severe  cases  reducing  ointments  give  appreciable  results : — 

Oil  of  Cade 10  grammes         5  fs 

Yellow  Oxide  of  Mercury  .     ~| 

Resorcine       I       aa     i  gramme       gr.  24 

Ichthyol J 

Lanoline ,  20  grammes  3j 

The  formula  must  be  altered  to  suit  each  case. 

Electric  treatment  by  high  frequency  currents  is  based  on  the 
hvpothesis  that  the  lesion  is  a  neuro-dermatitis,  but  does  not  appear 
to  give  constant  results. 


THE    NAPE    OF    THE    NECK.  173 

The  X-rays  may  be  employed  in  small  doses  of  2  or  3  units  H,  or 
a  half  tint  B  of  the  radiometer  X  (p.  196),  in  order  to  disperse  the 
chronic  subjacent  oedema  of  the  lesion. 


THE   SCALP. 

The  scalp  is  a  region  of  great  importance,  owing  to  its  extent  of 
surface  and  to  the  variety  of  dermatological  affections  of  which  it 
may  become  the  seat.  Following  the  plan  of  this  book,  we  shall 
divide  this  large  chapter  into  three  smaller  ones,  the  first  of  which 
will  include  diseases  of  the  scalp  in  infancy ;  the  second,  diseases  of 
the  scalp  in  adolescence;  and  the  third,  diseases  of  the  scalp  in  old 
age. 

This  classification  is  obviously  somewhat  artificial  and  those  affec- 
tions which  are  common  to  all  ages  may  be  found  equally  in  the 
three  chapters.  If  the  reader  does  not  find  in  one  chapter  what  he 
seeks,  he  will  discover  it  in  the  two  others.  ^My  excuse  lies  in  the 
fact  that  nature  does  not  accommodate  herself  to  our  requirements 
of  order  and  classification. 

THE  SCALP  IN  CHILDREN. 

From   the   first   months   the  scalp   of  the   i>tfallt^ 
may  present  the  fatty  epidermic  secretion  knoivn  asV        "  ''  ^  P     °  * 

"skullcap" J      Nurslings      .    .   p.  175 

.    .    .   and   an   alopecia   of   the   occipital   r^g/on"]  Occipital        A  1  o  - 

peculiar  to  infants  of  early  age J      pecia p.  176 

At  an  early  age  vascular  and  icarty  nacvi  occur, -^ 
which   persist  during   life " jNaevi p.  176 

Connected  with  these  naevi  is  a  congenital  />a/c/:'>  Congenital  Alo- 
of  alopecia  zi.'hich  is  often  only  noticed  later  .    .    .J      pecia p.  177 

Insufficient  or  excessive  development  of  the  hair  Atrichia.  Hyper- 
in    infants    merits   attention y     trichosis    ...   p.  177 

Among  the  dystrophies  of  the  hair  zl'c  must  men-y  ,,      .....    .  „ 

,  ,.  ,  ....  ,    .  LMonilithnx   .   .    .   p  178 

tton  tliat  which  causes  moniliform  hairs J 

.    .    .   and  ichthyosis  of  the  scalp,  zi'hich  always^  t   1  .^1 

.  ,    .  ,    ,        ■       ,    ,      ,     ,                           "    1  Ichthyosis     ...    p.  170 
co-exists  with  ichthyosis,  of  the  body r 

A  fezv  words  must  also  be  said  of  the  peculiar^ 
habit  of  infants,  consisting  in  incessant  aM/owa/;V  iTrichotillomania    p.  180 
epilation 

There  exists  a  chronic,  dry  and  scaly  circum-^  False  ringworm, 
scribed  dermatitis,  called  tinea  amiantacea  by  Ali-\  Tinea  amian- 
bert  and  Devcrgie f     tacea p.  180 

Pediculosis   of  the   scalp   occurs  at  all  ages,   aZ-i  d^j-     1     •  o 

,,.,,,',,'  ,     .      f.,,       IPediculosis  .    .    .  p.  i8i 

least  tn  the  female,  but  more  commonly  in  children j 


THE    SCALP. 


i/S 


The  scalp  presents,  either  together  or  separately, 
the  two  dermatological  types  of  impetigo.  We 
shall  first  study  true  impetigo  with  honey-like 
crusts 

.  .  .  and  the  multiple  areas  of  alopecia  to  which-, 
it  gives  rise  . J 

JVe  shall  next  study   the  impetigo   of  Bockhart~\ 

(pustular-follicular) j 

.    .    .   The    furnucles    and    follicular    abscesses^ 
zi'hich   often   follow r 

.  .  .  The  post  and  perifufuncular  alopecias^ 
which  follow  this  scries  of  follicular  pustules  ...  J 

.    .    .   and   the  atrophodermic  alopecia  zvhich   is^ 
connected  with  this  series,  for  it  is  consecutive  to 
a    follicular    nucleus    which    is    absorbed    without 
opening   

PVe   shall   next   review   the   series   of   traumatic^ 
and  cicatricial  alopecias  which  occur  on  the  infant's 
scalp 

Lastly,  infantile  eczema  zvill  occupy  our  attention^ 
under    the    impetiginous    form;    or    dry    red    and 
chronic,  occurring  at  the  academic  age 

IVe  next  come  to  the  natural  group  of  crypto- 1 
gamic  ringworms.  We  shall  study  -first  the  small  I 
spored  ringworm,  or  microsporon 


Impetigo  contag- 
iosa of  T.  Fox  p.  182 

Post-impetiginous 
Alopecia    ...  p.  182 

Impetigo  of  Bock- 
hart     p.  183 

Furuncle.  Follicu- 
lar abscess   .    .  p. 185 

Post-furuncular 
Alopecia    ...   p.  185 

Atrophodermic 

Alopecia    ...   p.  187 

Traumatic  and  ci- 
catricial Alo- 
pecia   p.  188 


Eczema 


.   p.  188 


.    .    .   Then  the  common  ringworm  of  children   .\ 

.  .  .  Then  the  rare  ringzvorms  of  animal  origin,'} 
with  abnormal  symptoms  and  inflammatory  reac- 1 
tion;  and  among  them  Kerion 

The  treatment  of  ringworms  will  be  treated  c.l-\ 
some  length j 

.    .    .  Especially   the   treatment    by  X-rays  •    •      j 

For  those  who  have  not  a  radiothcrapcutic  in-"] 
stallation,  we  must  describe  the  therapeutics  of  ring-  I 
worm  before  the  discovery  of  the  X-rays I 

After  these  chapters  on  treatment  we  shall  study^ 
favus  in  its  three  clinical  varieties:  the  cupped  \ 
form,  the  pityriasiform  and  impetiginous  forms  .    . 

We  shall  conclude  this  chapter  with  a  short  study-\ 
of   ophiasic   alopecia    of   infants j 


Small  spored  ring- 
worm     ....   p.  189 

Large  spored  ring- 
worm     .    .    .    .   p.  igi 

Ringworm  of  ani- 
mal origin,  Ker- 
ion Celsi   ...   p.  195 

Treatment  of  ring- 
worm     ....   p.  196 

Radiotherapy  o  f 
ringworm  ...   p.  196 

Former  treatment 
of  ringworm    .   p.  199 

Favus p.  199 

Ophiasis    ....   p.  202 


THE    SKULL  CAP    OF    NURSLINGS. 

Under  this  name  is  understood  a  progressive  agglomeration  o'' 


176  THE    SCALP. 

epidermic  debris,  more  or  less  solid  or  pasty,  forming  an  adherent 
yellow  layer  on  the  scalp  of  the  young  infant.  This  dries,  hardens 
and  becomes  like  brown  paper,  when  allowed  to  remain.  Some 
&calps  have  a  greater  tendency  than  others  to  form  this  crust,  which 
was  formerly  often  respected  by  nurses.  After  a  time  the  stagnation 
of  epidermic  debris  causes  irritation  of  the  subjacent  skin  and  the 
formation  of  purulent  exudation.  This  complication  is  due  to 
neglect  and  may  lead  to  incomplete  but  permanent  alopecia  of  the 
region  of  the  vertex. 

Even  in  less  severe  forms  this  condition  requires  treatment  by 
weak  applications  of  oil  of  cade  or  tar,  with  glycerole  of  starch. 
These  should  be  washed  off  in  the  morning  with  ordinary  soap  and 
a  badger  hair  brush.  The  crusts  resist  removal  owing  to  being 
adherent  to  the  hairs,  and  they  should  never  be  removed  by  any  hard 
instrument. 

OCCIPITAL  ALOPECIA. 

The  newly  born  often  present  alopecia  of  the  occipital  region, 
which  results  solely  from  rubbing  the  hair  on  the  pillow.  It  is  of 
an  oval  form  with  the  larger  diameter  transverse.  It  requires  no 
treatment,  but  may  lead  to  errors  of  diagnosis. 

NAEVL 

Nsevi  are  perhaps  more  common  on  the  scalp  than  anywhere  else. 
Vascular  naevi  or  "port  wine  stains"  are  irregularly  disposed  and 
hidden  by  the  hair.  The  most  common  nsevus  of  this  kind  is  situated 
in  the  occipital  fossa.  This  is  popularly  known  as  "original  blemish." 
It  is  of  no  importance,  except  that  it  may  be  mistaken  for  a  disease ; 
or,  when  a  true  lesion  occurs  in  this  situation,  cause  an  appearance 
of  congestion. 

Flat  and  warty  n?evi  form  irregular  tracks  w-ith  clear  borders 
formed  by  papular  brown  elements  destitute  of  hairs.  Their  geo- 
graphical form  and  embossed  appearance  are  characteristic.  When 
small  they  may  only  be  noticed  by  chance.  The  parents  usually 
regard  them  as  congenital. 

As  long  as  naevi  of  this  kind  do  not  increase  in  size  they  require 
no  treatment ;  but  if  they  enlarge  they  should  be  treated  by  electro- 
lysis (p.  5). 


THE    SCALP. 
CONGENITAL    ALOPECIA. 


177 


By  the  side  of  nsevi  should  be  placed  a  congenital  alopecia,  fre- 
quently mistaken  for  alopecia  areata.  It  may  be  unilateral  or  bilat- 
eral, and  occurs  as  an 
oval  patch  of  alopecia 
about  23^  c  e  n  t  i  - 
meters  in  length  and 
lYz  in  width,  situated 
on  the  temple  and 
directed  obliquely 
from  above  back- 
wards. It  may  inter- 
sect the  margin  of  the 
scalp,  or  commence 
behind  it  (Fig.  68). 

The  parents  have 
never  seen  it  develop : 
it  persists  but  does 
not  increase  in  size. 
The  skin  is  somewhat 
thin  and  atrophic:  it 
is  not  quite  smooth 
but  bears  on  its  sur- 
face a  little  down. 

No  treatment  is 
efficacious.  The  etiol- 
ogy of  this  alopecic 
patch  is  unknown 
and  it  has  been  wrongly  attributed  to  the  application  of  forceps 
at  birth. 

ATRICHIA    AND    HYPERTRICHOSIS. 

The  development  of  the  hair  at  birth  and  during  infancy  varies 
considerably  in  different  subjects.  Some  children  are  born  bald, 
while  others  have  hairs  several  inches  long.  The  hairs  may 
even  be  darker  than  afterwards. 

Generally,  they  fall  six  weeks  or  two  months  after  birth,  and 
are  replaced  by  a  pale  downy  growth,  which   forms  the  new 


(Sabouraud's   patient.     Photo,   by   Noir$.) 
Fig.  «8.     Congenital    temporal    alopecia. 


178  THE    SCALP. 

hair.  Some  subjects  preserve  a  very  poor  head  of  hair  during 
their  whole  infancy,  formed  by  fine  and  scanty  hairs.  I  do  not 
consider  this  a  bad  omen  if  it  is  not  excessive.  When  the  hair 
is  mediocre  at  8  or  lo  years  it  often  develops  at  puberty  and 
remains  good  in  the  adult.  When  it  is  too  good  before  full 
development  it  is  generally  invaded  by  pityriasis  at  12  or  14 
years,  which  becomes  steatoid  at  the  age  of  15  to  18  and  causes 
loss  of  hair  of  a  paroxysmal  and  progressive  character,  which  is 
established  between  the  ages  of  18  and  20  and  persists  during 
life  (see  pp.  207  &  208). 

Poor  heads  of  hair  should  not  be  treated  before  puberty  as 
long  as  there  is  no  visible  deformity.  In  this  case  stimulating 
lotions  may  be  tried,  but  they  give  little  result. 

Spirit  of  lavender 25  grammes  3j 

Alcohol,  60  per  cent 250           "  3j 

Distilled  water 25          "  3j 

Hydrochlorate  of  pilocarpine        50  centigrammes  gr.  i 

Ointments  of  oil  of  cade  applied  at  night  and  washed  off  in  the 
morning  often  give  better  results. 


MONILITHRIX. 

Alonilithrix  is  one  of  the  most  singular  deformities  of  the  hair 
which  is  met  with.  The  hair  appears  formed  by  a  series  of 
swellings  and  constrictions,  the  swellings  being  of  the  diameter 
of  the  normal  hair.  All  the  hairs  of  the  head  may  be  affected, 
or  nearly  normal  hairs  may  be  mixed  with  moniliform  hairs  in 
all   proportions. 

The  moniliform  hairs  are  fragile  at  the  points  of  constriction, 
and  when  they  are  numerous  there  are  always  short  and  ir- 
regular hairs  in  the  head.  In  the  most  severe  cases  there  are 
scarcely  any  hairs  at  all :  they  are  replaced  by  a  red  point,  a 
horny  elevation,  resembling  that  of  keratosis  pilaris,  and  affect- 
ing the  whole  scalp.  Here  and  there  are  found  the  debris  of 
moniliform  hairs. 


THE    SCALP. 


179 


In  less  marked  cases  the  hair  appears  scanty,  and  it  is  neces- 
sary to  examine  by  a  lens  to  see  the  moniliform  appearance. 

This  condition  is  not 
a  disease  but  the  result 
of  a  congenital  de- 
formity. It  is  a  con- 
sanguineous malforma- 
tion and  I  have  seen  29 
examples  in  the  same 
family  in  nine  genera- 
tions. The  children  are 
born  with  normal  hairs 
which  fall  after  six 
weeks  and  are  not  re- 
placed. The  moniliform  state  of  the  hair  increases  little  by 
little   with    age. 

Like  all  deformities  this  condition  is  incurable.  In  less  marked 
cases  some  improvement  may  perhaps  occur  after  eukeratosic 
ointments,  such  as  oil  of  cade,  applied  at  night  and  washed  off 
in  the  morning;  but  the  results  are  not  very  constant. 


Fig.  69.     Moniliform   hair.     Monilithrix. 
(Preparation   by    Sabouraud.      Photo,    by    Noire.) 


ICHTHYOSIS. 


Ichthyosis  of  the  scalp,  a  rare  malformation,  is  always  less 
marked  on  the  scalp  than  on  the  body  of  the  same  subject.  Diag- 
nosis is  thus  made  by  comparative  examination  of  the  scalp  and 
the  body. 

It  is  constituted  by  brown,  thin,  dry  squames,  adherent  to  the 
skin  and  separated  at  their  margins,  making  them  slightly  con- 
cave. The  crown  of  the  head  is  thus  covered  with  a  uniform, 
crusted  layer.  Removal  of  this  crust  exposes  a  red,  thin,  shiny 
skin,  and  many  downy  curled  hairs  come  away  with  the  crust. 
The  crown  of  the  head  is  nearly  bald,  or  at  any  rate  the  hairs 
are  scanty  even  when  the  crusts  are  left  alone.  This  condition 
leads  to  permanent  alopecia.  The  only  treatment  is  by  tar,  ap- 
plied daily  for  a  long  time  and  continued  once  a  week ;  this 
may  preserve  the  hair  to  a  certain  extent,  but  it  always  remains 
scantv. 


l8o  THE    SCALP. 

Oil   of  cade lo  grammes      ^fs 

Oil  of  birch T 

Ichthyol t  aa     I  "         gr.  24 

Resorcine J 

Lanoline 20  "  3j 

This  is  washed  off  in  the  morning  with  a  badger-hair  brush ; 
well  rinsed  and  dried. 

TRICHOTILLOMANIA. 

Sometimes  a  child  presents  large  irregular  patches  of  incom- 
plete depilation,  situated  chiefly  on  the  temples,  but  sometimes 
on  the  crown.  These  are  seen  to  be  riddled  with  small  black 
spots  of  hair  debris  inserted  in  the  skin,  which  I  shall  refer  to 
when  dealing  with  alopecia  areata  under  the  name  of  "hair 
bolus"  (p.  203,  Fig.  95).  There  are  always  tufts  of  healthy  hairs 
on  the  patch,  and  new  hairs  appear  of  different  sizes.  The  irregu- 
lar margin  of  the  patches  is  furnished  with  healthy  hairs.  There 
are  no  alopecic  hairs.  By  interrogating  the  parents  it  is  found 
that  the  child  epilates  itself  automatically  every  time  its  attention 
is  drawn  to  it  when  working,  reading,  etc.  This  habit,  which  we 
have  already  studied  with  the  morbid  conditions  of  the  mous- 
tache, may  occur  in  the  adult.  In  this  case  the  subject  is  rarely- 
well  developed  intellectually ;  but  the  habit  may  occur  in  a  child 
who  is  otherwise  normal.  The  treatment  belongs  to  the  domain 
of  neuropathology.  ' 

FALSE     RINGWORM.      TINEA     AMIANTACEA     OF     ALIBERT- 

DEVERGIE. 

The  morbid  condition  to  which  this  term  is  applied  is  a  chronic, 
dry,  squamous  epidermatitis,  limited  to  one  region  of  the  scalp, 
usually  the  vertex.  It  may  be  primary  or  secondary.  When  pri- 
mary it  develops  slowly  without  appreciable  cause  and  occupies 
the  whole  vertex.  This  is  covered  with  a  cap  of  imbricated 
squames,  including  the  hairs  which  lie  under  them,  so  that  when 
the  hairs  are  pulled  back  they  raise  a  large  squame  resembling 
a  fish's  scale ;  white  on  the  surface  and  yellow  in  depth.  Alibert 
described  a  primary  weeping  stage,  which  is  generally  absent. 

Between    primary    and    secondary    forms    of    false    ringworm 


THE    SCALP. 


i8i 


there  is  the  same  difference  as  between  eczema  and  artificial 
dermatitis.  The  secondary  form  arises  on  an  old  ringworm,  or  a 
patch  of  alopecia  areata,  after  cure.  It  occupies  exactly  the  seat 
of  the  primitive  disease  and  appears  to  be  consecutive  to  the 
traumatism  of  treatment.  Both  forms  are  easily  cured  by  applica- 
tions of  tar  and  its  derivatives. 

Oil  of  cade lO  grammes      5  fs 

Oil  of  birch 

Ichthyol      

Resorcine 

Pyrogallic   Acid 

Yellow  Oxide  of  Mercury  .    . 

Vaseline 


aa  gr.  24 


Lanolinc 


aa     ID  grammes  aa  5  fs 


This  is  applied  every  night  for  4  to  7  weeks  and  washed  off 

every   morning.     The  lesion   disappears  in  two  or 

^        three  wrecks,  but  if  treatment  is  discontinued  it  re- 

^^H        appears.     In  order  to  destroy  the  lesion  effectively 

^^^M        treatment  must  be  continued  for  double  the  time 

^^^M        which  is  apparently  required. 


PHTHIRIASIS. 


Fig.  70.       Egg 

o  f     pedicu- 
lous   capitis 

fixed        to 

hair. 
(Preparatio  n 

by      Sabour- 

aud.     Photo. 

by     Noir&.) 


We  have  described  in  the  region  of  the  nape  of  the 
neck  the  maximum  lesions  of  pediculosis  of  the 
scalp  (p.  165). 

This  occurs  to  a  less  degree  on  the  rest  of  the 
scalp.  The  head  louse  is  a  little  smaller  than  the 
clothes  louse.  It  is  of  dark  grey  colour  and,  like  all 
human  lice,  belongs  to  the  family  of  pediculi 
(Apterous  Hemiptera).  The  shiny  black  egg  forms 
a  small  oblong  pouch,  very  adherent  to  the  hair, 
which  it  ensheaths  with  a  chitinous  socket  (Fig. 
70).  The  egg  is  laid  close  to  the  skin  and  the  height 
above  the  skin  indicates  its  date. 

The  abrasions  of*  the  skin  made  by  the  lice  cause 
much  itching  and  are  often  complicated  by  one 
or  both  impetigos.  (Pedicular  impetigo).  The 
simplest  treatment  of  pediculosis  is  to  cover  the 
entire  scalp  for  several  hours  with  a  thick  layer  of 
vaseline,  which  penetrates  by  capillary  action  the 


i82  THE    SCALP. 

respiratory  tubes  of  the  parasites.  A  complete  cleansing  remeves 
the  vaseline  with  the  scabs  and  dead  lice.  The  eggs  are  softened 
with  warm  vinegar  and  removed  with  a  comb. 

IMPETIGO    CONTAGIOSA. 

Impetigo  contagiosa,  phlyctenular  and  streptococcic,  is  more 
common  on  the  smooth  skin  than  on  the  scalp ;  while  follicular, 
pustular  and  staphylococcic  impetigo  is  more  common  on  the 
scalp.  It  is  usually  secondary  to  pediculosis  and  mixed  with 
the  impetigo  of  Bockhart.  In  the  nape  of  the  neck  the  lesions 
are  confluent,  but  more  discrete  elsewhere. 

Impetigo  is  seldom  seen  on  the  scalp  except  in  the  course  oi 
impetigo  of  the  face,  when  the  evolution  of  the  lesions  is  iden- 
tical. It  may,  however,  occur  in  the  form  of  a  large  patch  of 
slow  evolution,  which  may  cover  an  area  of  several  inches 
{impetigo  scahida  of  Willan).  Impetigo  has  everywhere  the 
usual  characters ;  the  thick  amber  coloured  crust,  of  the  con- 
sistency of  honey,  covering  an  exulceration,  exuding  abundance 
of  clear  serum,  and  covered  with  a  thin  layer  of  fibrin  giving 
it  a  pale  lilac  colour.  When  the  crusts  coalesce  they  become 
hard,  especially  in  phtiriasis ;  and  in  the  large  impetiginous 
placards  of  slow  evolution  the  crust  has  the  appearance  of  the 
bark  of  a  tree. 

In  secondary  impetigo  the  treatment  is  that  of  the  cause. 
That  of  impetigo  is  the  same  in  all  situations: — sulphate  of  zinc 
lotion  (i  per  cent)  ;  nitrate  of  silver  (i  in  15)  ;  protective  pastes, 
used  with  discretion,  for  excess  necessitates  difficult  cleansing. 

POST-IMPETIGINOUS     ALOPECIA. 

The  lesions  of  impetigo  develop  slowly  on  the  scalp,  because 
the  hair  keeps  the  crusts  in  place  under  which  suppuration  is 
produced.  When  the  crusts  fall,  the  hairs  often  come  with 
them,  leaving  smooth  surfaces  as  large  as  the  crusts,  the  size  of  a 
:sixpence  to  a  shilling.  The  skin  is  red  and  smooth,  and  distinct 
hy  its  colour  from  the  surrounding  skin.  Even  when  the  crust 
has  fallen,  parts  of  it  are  found  adhering  to  the  hair  round  the 
patch.  The  eruption  of  impetigo  may  include  from  6  to  10  lesions, 
each  giving  rise  to  a  patch  of  alopecia,  and  all  appearing  almost  at 
the  same  time.     In  the  common  people  the  crusts    may    not    be 


THE    SCALP. 


183 


noticed  and  the  alopecia  appears  to  be  primary.  Impetigo  is 
contagious  and  epidemic,  also  endemic  in  schools.  The  post- 
impetiginous  patches  of  alopecia  are  then  mistaken  for  patches 
of  epidemic  and  contagious  alopecia  areata.  This  is  the  history 
of  nearly  all  the  so-called  epidemics  of  alopecia  areata  in  schools, 
and  the  others  are  epidemics  of  ringworm.  The  differential  diag- 
nosis from  alopecia  areata  is  made  by  the  simultaneous  appear- 
ance of  the  patches ;  their  size  and  identity  in  dimensions ;  the 
presence  of  the  crust  or  its  remains ;  the  co-existence  of  impetigo 
of  the  face,  or  its  marks ;  the  redness  of  the  skin ;  the  absence 
of  club  shaped  hairs  around  the  bald  areas,  and  the  rapid  and 
regular  growth  of  downy  hairs  on  all  the  denuded  surfaces. 
Treatment  is  useless,  but  always  followed  by  good  results 
which  would  have  occurred  without  it.  If  it  is  necessary  to 
prescribe,  the  following  may  be  applied : — 


Vaseline 

Tannin 

Calomel 


30  grammes  5J 

-  aa     30  centigrammes     gr.  5 


This  may  be  cleansed  in  the  morning  with  one  part  of  resorcine 
in  100  of  Hoffmann's  liquor. 


IMPETIGO    OF    BOCKHART. 

This  is  one  of  the  commonest  diseases  of  the  scalp  in  children. 
The  elementary  lesion  is  a  pustule,  of  a  greenish  yellow  colour, 

and  pierced  by  a 
hair.  This  pustule 
appears  like  a  millet 
seed  in  the  middle  of 
a  red  spot.  It  may 
attain  the  size  of  half 
a  cherry  stone  (Fig. 

During  its  active 
evolution,  which 
lists  from  4  to  6 
days,  the  pustule  re- 
ni  a  i  n  s  surrounded 
bv     a      red      areola. 


A-,^ 
^ 


Tig.  71.     Elementarv  lesions   of  the   foUicular  impetigo 
of     Bockhart.      Semi-diagrammatic     (Sabouraud.) 


i84 


THE    SCALP. 


When  it  is  opened  a  drop  of  pus  streaked  with  blood  emerges.  It 
usually  dries  without  opening  and  forms  a  hard  lenticular  scab^ 
which  may  remain  in  place  for  one  or  two  weeks. 

This  pustule  is  the  element  of  eruptions  of  varying  degrees  of 
intensity.  Sometimes  a  crop  of  4  to  10  pustules  only  is  formed^ 
at  other  times  500  or  more.  All  are  accompanied  by  sub-occipital 
adenopathy.  Some  eruptions  persist  because  they  consist  of 
small  subinvoluted  crops. 

This  affection  is  often  transient,  but  more  often  recurrent  and 
remarkably  tenacious,  sometimes  lasting  for  months  or  years. 

It  may  be  pri- 
mary without 
any  known 
cause, or  secon- 
dary to  the 
treatment  for 
ringworm,  alo- 
p  e  c  i  a  areata, 
pediculosis,^ 
etc.  In  this 
case  it  may  sur- 
vive the  orig- 
inal cause  for 
some  time. 

^^'  hen  the 
eruption  p  e  r- 
sists,  old  and 
young  lesions 
c  o-  e  X  i  s  t,   the 

older  ones  often  forming  only  a  red  punctiform  cicatrix  in  the 
centre  of  a  bald  spot.  Others  degenerate  into  furuncles  or  furun- 
cular  abscess. 

The  treatment  of  this  affection  is  diflficult,  succeeding  in  mild 
cases  but  failing  in  severe  ones.  The  best  preparations  are  sul- 
phur lotions  and  ointments : — 


rig.  72.     Pustular    impetigo    of   Bockhart    of   the    scalp. 
(Sabouraud's    patient.     Photo,    by    Noir4.) 


(i)  Precipitated    Sulphur 

Lanoline 

Vaseline 


3  grammes     gr.  48 
aa     IS  "  S<s 


THE    SCALP.  185 

(2)  Alcohol  60  per  cent 20  gramme  4         3  ii 

Precipitated    Sulphur 10  "  3j 

Rose    water 70  "  3j 

This  affection,  like  impetiginous  eczema,  may  occur  in  young 
people  affected  with  albuminuria,  with  or  without  renal  lesions, 
and  in  these  cases  it  is  difficult  to  cure.  The  same  chronicity  may 
be  observed  without  any  perceptible  cause.  It  may  be  always 
cured   by   time. 

FURUNCLES  AND   PERIFURUNCULAR  ABSCESS. 

The  impetigo  of  Bockhart  consists  of  follicular  pustules.  If 
the  staphylococcic  infection  which  gives  rise  to  them,  extends 
the  length  of  the  follicle  and  multiplies  deeply,  a  furuncle  or 
furuncular  abscess  is  formed.  These  are  different  forms  of  the 
same  affection  and  may  often  occur  in  the  course  of  impetigo  of 
Bockhart. 

The  furuncle,  when  mature,  evacuates  a  solid  necrotic  core, 
while  the  follicular  abscess  discharges  a  few  drops  of  pus.  Moist 
dressings  form  the  best  application,  after  epilation  of  the  central 
hairs  of  the  lesion.  When  the  furuncle  or  abscess  points  it 
should  be  punctured  with  the  galvano-cautery.  This  relieves 
pain  and  hastens  the  evacuation  of  the  core  or  pus. 

Local  treatment  of  furuncle  by  tincture  of  iodine,  iodised 
acetone  or  camporated  alcohol  externally,  and  general  treatment 
by  phosphorous,  yeast,  etc.,  have  been  recommended ;  but  none 
of  these  forms  of  treatment  are  constant. 

POST-  AND  PERIFURUNCULAR  ALOPECIA. 

The  follicular  pustules  of  impetigo  of  Bockhart,  and  still  more, 
furuncles  and  perifuruncular  abscess  give  rise  to  alopecia  in  round 
areas,  3  or  4  millimetres  in  diameter,  after  a  simple  pustule, 
or  from  i  to  i^  centimetres  after  a  furuncle  or  follicular  abscess 
(Fig.  74).  In  the  case  of  an  eruption  of  simple  impetigo  of  Bock- 
hart, the  head  is  riddled  with  small  alopecic  points  in  equal  num- 
bers to  the  pustules,  each  presenting  a  punctiform  cicatrix  in 
the  centre. 


i86  THE    SCALP. 

This  alopecia  is   quite  characteristic   and  it  is  hardly  neces- 


Fig.  73.     Alopecia    after    impetigo    of   Bockhart    of    the    scalp. 
(Sabouraud's    patient.     Photo,     by     Noir6.) 

sary  to  add  that  it  has  nothing  in  common  with  alopecia  areata 


Fig.  74.     Temparal     alopecia    consecutive    to     a.    furuncle,     of    which     the    central 

cicatrix    is    seen, 
(Sabouraud's    patient.     Photo,    by    Nolr6.) 


THE    SCALP. 


187 


that  it  is  no  longer  contagious  and  allows  the  child  who  pre- 
sents it  to  go  to  school. 

When  there  has  been  a  furuncle,  the  alopecia  is  larger  but 
retains  the  same  characters  and  the  same  central  cicatrix  (Fig. 

74).  The  bald  area 
is  not  bordered  with 
the  club  shaped  hairs 
of  alopecia  areata, 
but  the  dead  hairs, 
when  removed,  are 
often  bent  at  the 
radicular    end    (Fig. 

75).  _ 

This  alopecia  is 
cured  without  treat- 
ment, but  the  dura- 
tion of  baldness  is 
longer  than  that  of 
Even    when    it    is    cured. 


Fig.  75.     Dead  hair  from  a  furuncle. 
(Preparation   by    Sabouraud.     Photo,    by    Noir6.) 


post-impetiginous    alopecia   (p.    182) 

smooth  cicatrices  remain  in  the  place  of  each  lesion 


ATROPHODERMIC    ALOPECIA. 

This  is  a  rare  lesion,  always  mistaken  for  alopecia  areata, 
which  should  be  placed  among  the  alopecias  mentioned  above. 

In  the  course  of  impetigo  of  Bockhart,  or  even  apart  from  any 
pustular  eruption,  a  deep  follicular  infection  arises  which  forms 
a  small  furuncular  abscess  close  to  a  follicle.  This  little  abscess 
slowly  aborts  and  is  absorbed.  It  produces  an  alopecic  area  as 
large  as  a  sixpence,  accompanied  by  local  cutaneous  atrophy. 
This  area  may  persist  for  6  or  15  months.  The  symptoms  are 
negative ;  it  does  not  show  the  club  shaped  hairs  of  alopecia 
areata.  It  is  single  and  does  not  increase  in  size,  but  persists 
for  a  long  time.  A  small  nodosity  may  be  felt  for  some  time  in 
the  centre  of  the  patch,  which  is  the  abscess  in  process  of  reso- 
lution, but  this  symptom  itself  disappears.  Growth  of  the  hair 
recurs  after  a  year,  but  for  some  time  afterwards  the  hairs  re- 
main downy  and  the  patch  retains  its  atrophic  concavity. 

The  treatment  consists  in  slight  irritation,  continued  for  some 
time,  by  applications  of  glacial  acetic  acid  in  spirit  of  ether   (2^ 


i88  THE    SCALP. 

per  cent)  ;  alcoholic  solution  of  lactic  acid   (20  per  cent)  ;  or 
iodine  in  rectified  benzine  (8  per  cent). 

TRAUMATIC    AND    CICATRICIAL    ALOPECIA. 

An  alopecia  may  be  caused  by  a  contusion,  if  the  shock  is, 
violent,  and  every  skin  has  its  co-efficient  in  this  respect,  a 
slight  shock  being  in  some  cases  sufficient  to  cause  a  patch  of 
alopecia.  In  this  case  the  alopecia  is  transient,  lasting  for  the 
length  of  time  necessary  for  the  hair  to  reproduce  itself;  about 
six  weeks. 

Cicatrices  consecutive  to  a  wound  are  geometrical,  linear  or 
angular,  and  their  shape  gives  evidence  of  their  origin.  The 
cicatrices  of  abscesses  are  stellate  and  depressed ;  those  of 
furuncle,  punched  out  and  polygonal,  and  those  of  chronic  sup- 
purations, corrugated  or  smooth. 

A  cicatrix  is  often  mistaken  for  non-cicatricial  alopecia,  but 
in  the  latter  the  follicular  orifices  are  always  visible,  while  absent  in  a 
cicatrix.  This  is  important  to  bear  in  mind,  for  I  have  several  times 
seen  a  cicatrix  mistaken  for  alopecia  areata  and  treated  in  the  hope 
of  reproducing  the  hair !  All  treatment  of  a  cicatrix  with  this  object 
is  illusory.  The  transplantation  of  hairs  in  deep  scarifications  made 
in  cicatrices  has  been  practised  by  Hodara,  but  up  to  the  present  its 
value  is  only  theoretical. 

ECZEMA    OF    CHILDREN. 

Eczema  of  the  scalp  in  children,  between  3  and  10  years  of  age, 
is  nearly  always  mixed  with  impetigo.  Sometimes  the  impetigo  is 
primary  and  is  characterised  by  retro-auricular  streptococcic  inter- 
trigo, blepharitis,  etc.,  and  sometimes  by  the  impetigo  of  Bockhart. 
The  eczematous  condition  which  is  superadded  gives  rise  to  a  chronic 
red  dermatitis  which  is  dotted  with  suppurating  follicles. 

At  other  times  the  eczema  is  primary  and  the  streptococcus  is 
grafted  on  it,  creating  impetiginisation  of  the  eczematous  surfaces : 
or  a  surface,  at  first  eczematous,  may  be  riddled  with  secondary 
follictilar  pustules. 

Eczema  o^  the  scalp  is  never  limited  exclusively  to  the  scalp  and 
is  always  characterised  by  punctate  epidermic  orifices,  hardly  visible 


THE    SCALP.  189 

to  the  eye,  which  exude  minute  serous  drops.  This  form  of  eczema 
is  often  connected  with  a  general  condition.  The  child  is  puny,  with 
a  pale  complexion  and  oedematous  skin.  It  may  have  intermittent 
albuminuria  and  diminished  acidity  of  the  urine.  The  duration  of 
this  aflfection  is  variable,  lasting  for  months  or  years ;  and  it  is 
liable  to  recurrence. 

The  first  condition  of  treatment  is  change  of  air,  if  possible  at  the 
seaside.  These  forms  of  eczema  are  benefited  by  sea  air.  Local 
treatment  is  the  same  as  for  ordinary  impetigo,  by  zinc  sulphate  lo- 
tion (i  per  cent);  nitrate  of  silver  (i  in  15);  zinc  paste  (half 
strength),  etc.  In  impetiginous  eczema,  or  in  eczematised  impetigo, 
mild  tar  ointments  give  good*  results : — 

Oxide  of  Zinc 1  _., 

Oil  of  Cade J    ^^     5  grammes       3ifs 


Vaseline 1  ,  . 

r    aa  15  grammes         3  is 


Lanoline J    ^^  ^5  grammes 


^'       .       -        .*- 


SMALL  SPORED  RINGWORM   (MICROSPORON). 

Small  spored  ringworm  is  the  most  common  of  the  ringworms: 
i.e.,  diseases  of  the  epidermis  and  hair  caused  by  a  cryptogamic  para- 
site. It  is  characterised  by  dry,  squamous  patches,  from  i  to  2 
inches  in  diameter,  nearly  circular  and  with  well  defined  borders. 
The  hairs  on  these  patches  are  less  numerous  than  in  the  normal 
hair.  Some  hairs  preserve  their  characters,  but  others  are  broken 
off  a  short  distance  above  the  skin,  and  covered  with  a  grey  coat- 
ing (Fig.  yy).  These  break  off  at  the  level  of  the  skin  when  they 
are  epilated.  A  dozen  grey  stumps  may  be  removed  together  by  the 
fingers,  and  this  differentiates  this  form  of  ringworm  from  all  others. 

Sometimes  the  disease  occurs  in  the  form  of  a  single  large  patch ; 
at  other  times  there  may  be  five  to  ten  smaller  patches.  These 
patches  may  coalesce  and  form  a  large  patch,  more  or  less  polycylic. 
This  form  of  ringworm  may  eventually  cover  the  whole  head,  except 
in  places  where  islands  of  healthy  skin  and  hair  are  left.  The  dis- 
ease is  extremely  slow  and  chronic  and  when  left  to  itself  persists 
for  2  to  7  years  and  terminates  in  spontaneous  cure  at  about  the 
15th  year.  The  old  patches  resemble  finely  squamous  eczema  with 
scattered  hairs.  Sometimes  small  spots  of  ringworm  remain  in  a 
healthv  head  of  hair.    These  form  small  grey  areas  on  which  a  few 


THE    SCALP. 


long  ringworm  hairs  may  be  recognized  by  their  grey  covering  and 
fragihty. 

The  disease  is  contagious  during  its  whole  duration.  The  first 
place  inoculated  forms  a  red,  slightly  papu- 
lar macvila,  situated  near  the  margin  of  the 
scalp ;  an  erythema  in  the  form  of  a  rosette 
(Fig.  yy).  The  redness  disappears,  the 
hairs  are  attacked  and  become  friable,  and 
the  patch  becomes  squamous  on  its  whole 


FUr.  76.     Small     spored     ringworm,      ery- 
thematous    at     its     onset. 
(Vidal's    patient.     St.    Louis    Hosp.    Mu- 
seum,   No.    612.) 


Fig.  77.  Hairs  affecttd 
with  small  spored  ring- 
worm   magnified. 

(Sabouraud's  preparation. 
Photo    by    Noir6.) 


surface.  This  disease  is  eminently  contagious  and  epidemic.  It 
occurs  in  schools,  where  it  may  attack  almost  at  once  two-thirds  or 
three-quarters  of  the  children  in  a  few  weeks. 

Microscopic  examination  of  the  hair  confirms  the  diagnosis,  and 
should  be  practised  on  the  short  broken  hairs,  removed  by  the 
fingers.  When  warmed  between  tw-o  slides  in  a  drop  of  liquor 
potassae  and  examined  with  a  power  of  loo  to  300  diameters  and  a 
small  diaphragm,  the  hair  shows  a  covering  of  small  highly  refrac- 


THE    SCALP. 


191 


tive  spores,  placed  irregularly  side  by  side.    According  to  a  classic 
comparison  the  hair  resembles  "a  rod  coated  with  paste  and  rolled 

in  sand."  These  char- 
acters distinguish  this 
species  of  ringworm 
from  all  others,  and  its 
parasite,  the  Microspo- 
ron  Andouini  from  all 
the  trichophytons  and 
from  the  Achorion  of 
favus.  It  can  easily  be 
cultivated  on  various 
solid  media,  especially 
a  sugary  medium,  and 
forms  in  a  few  weeks 
a  circular  radiating  cor- 
pet  of  white  silky  down, 
which  is  most  charac- 
teristic (Fig.  81). 

There  are  three  varie- 
ties   of    this     parasite 

Fl|f.  78.     Small   spored   ringworm,   with    patches    In   the   L-tirmrn     Kp>cirlAc   fVi^   Tin 
form  of  rosette.      Half  the  scalp   has  been  K.UUWII,    UCSlue^    LIIC   liu- 

epilated.     (Sabouraud's  patient.)  ^^^  ^p^^-^g  .  ^^^  -^^  ^^^ 

horse  and  one  in  the  dog.  They  may  be  inoculated  in  man  on  the 
smooth  skin,  and  form  large  erythematous  patches,  and  on  the  beard. 
On  the  beard,  as  in  the  animal,  these  varieties  of  ringworm  imitate 
exactly  the  microsporon  of  the  child's  scalp  in  all  its  symptoms.  The 
treatment  of  this  affection  and  of  other  forms  of -ringworm  will 
be  explained  later  on  (p.  196). 


LARGE    SPORED   RINGWORM. 


This  form  of  ringworm  is  rather  less  common  than  the  preceding 
and  also  more  difficult  to  recognise.  It  is  characterised  by  very 
numerous  diseased  points  marked  by  a  small  heap  of  adherent 
squames,  resembling  a  dry  crust.  The  diseased  hairs  are  imbedded 
in  the  squames.  In  order  to  examine  them  the  squames  must  be 
raised,  when  they  appear  on  the  under  surface  as  small,  white  curved 
roots.    When  the  crusts  have  been  removed  by  appropriate  treatment 


J92 


THE    SCALP. 


^H^B 

_»IMI 

ito 

■^^^y 

^^^^^^^1 

^^^^K^^^^pS^'^'-'"' ' '' 

^ 

^H 

^^^^^^^^^^^^^^^^^^^^^^^^^^^^1 

^^^^^^^^k1- 

^^H 

^^^^^^Hl 

^^^^ 

^» 

^ 

■ 

■_ 

1 

^^H 

B 

1 

^^^^^^^^^^^^H 

HHElKawMBGpaa 

MB^- 

3 

FIk.  79.     Hair  from  small   spored   ringworm:    enlarged   3" 
(Sabouraud's    preparation.     Photo,    by    Noir6.> 


0W 


j:ps?:3i?v,;,:^s^- 


t^^^^^i 


4^' 


■!!■  —  -  -li-'      — '■•■-•.     '  '^ 


f  f<ARMANSKi 


'- .  '''"'  ^'  n 


Fig.  80.     Hair  from   small   spored   ringworm:    enlarged    300   diameters. 
(Sabouraud's    preparation.     Drawing    by     Karmanski. ) 


THE    SCALP. 


193 


Fig.  81.  Culture  of  Micro- 
sporum  Audouini  on  glu- 
cosised  gelose-peptone,  4 
per  cent.  Natural  size:  3 
weeks   old. 

(Sabouraud's  prepara  t  i  o  n  . 
I'hoto.     by    Noir6.) 


the  hairs  appear  as  short  black  curved  stumps  lying  on  the  skin  and 
covered  by  the  horny  layer  of  the  epidermis.  They  cannot,  there- 
fore, be  removed  by  the  fingers  or  even  by  forceps,  but  must  be  raised 

with  a  needle.  By  the  microscopic  ex- 
amination of  these  remains  of  hairs  diag- 
nosis can  only  be  made.     (Fig.  83.) 

The  technique  of  examination  and 
culture  are  the  same  as  for  microsporon 
(p.  190).  The  parasite,  with  the  same 
magnification,  appears  formed  of  much 
larger  spores  than  those  of  the  micro- 
sporon, and  arranged  in  regular  mycelial 
chains.  All  these  chains  forming  an  ar- 
rangement of  parallel  filaments  are  con- 
tained in  the  hair  {Trichophyton  endo- 
thrix).  The  culture  on  i  per  cent  gelose- 
peptone,     glucocised     to     4     per     cent. 

has     a     characteristic     crateriform     appearance     (Fig.     84).       In 

distinction    to    the  small 

spored  ringworm  the  large 

spored  form  consists  of  nu- 
merous small  patches  con- 
taining from  10  to  5  hairs, 

or  even  less  ;  larger  patches 

are  rare.     It  is  difficult  to 

distinguish  by  the  eye  the 

absence     of     the     missing 

hairs,  for  it  is  not  the  hair 

that  is  seen  but  the  multiple 

points    of   pityriasis.      The 

diagnosis,    difficult    in    the 

case  of  short  hair,  is  almost 

impossible  when  the  hair  is 

worn  long.     In  these  cases 

the  disease  is  often  revealed 

by    accessory    inoculations 

on  the  smooth  skin  of  the 

face  or  neck ;  red  maculse, 

forming  as  they  enlarge  segments  of  circles,  finely  vesicular  at  their 

margins. 


Fig.  83.     Stumps    of    hairs,    seen    with    a    lens    as 

they   appear    under   the   epidermis. 

(Sabouraud's    preparation.      Photo,     by    Noirf.) 


13 


•194  THE    SCALP. 

This  disease,  like  the  preceding,  is  contaifious  and  epidemic,  and 


rig.  83.     Hair    from     large    spored    ringworm.     Enlarged     250     diameters. 
(Sabouraud's    preparation.     Photo,    by    Rothier.) 

endemic  in  the  infantile  population  of  all  great  centres.     It  is  of 

very  slow  evolution  and  long 
duration,  some  cases  persisting 
for  8  or  lo  years,  and  even  ex- 
tending beyond  puberty  in  young 
girls.  It  generally  terminates  by 
spontaneous  cure,  without  leav- 
ing any  trace.  The  treatment  is 
dealt  with  later  on   (p.   196). 

The  trichophytons  form  a 
cryptogamic  family,  the  species 
of  which  vary  in  different  coun- 
tries. Numerous  species  co-ex- 
ist in  each  country,  each  having 
its  special  localisations  and  clini- 
cal type,  which  are  more  or  less 

FIs:.  84.     Culture       of      large      spored  ' 

ringworm    on    glucocised    gelose-  reCOgTlisable     (sCC    RiugWOrm    of 
peptone  »  \  o 

(Sabouraud's      ^ulture.       Photo.       by  ^^6  bcard    (p.    1^7) . 


THE    SCALP. 
RINGWORM    OF   ANIMAL   ORIGIN. 


195 


On  the  scalp  of  the  child  there  occur  types  which  are  much  less 
common  than  the  preceding  ones.    Their  culture  is  acuminate,  brown 


Fig.  85.     Cultures  on   glucocised   gelose-peptone   showing  the   three   chief  parasites 

of    ringworm.      From    right    to    left    Microsporon    Audouini:    Trichophyton 

crateriforme:     Trichophyton    accuminatum. 

(Cultures   by    Sabouraud.     Photo,    by   Noir6.) 

or  violet  (T.  acuminatum:  T.  violaccum).  The  ringworm  which 
they  cause  on  the  scalp  of  the  child  is  identical  with  the  preceding, 
except  that  there  is  a  large  primary  patch  around  which  secondary 
points  occur  with  decreasing  frequency. 

The  Trichophyton  violaceum  may  form  on  the  neck  a  poly-circi- 
nate  ringworm  of  elegant  design.    It  may  invade  the  scalp  in  women 

in  rare  cases  (one  case  of 
28,  another  of  62  years). 
It  has  also  been  observed 
in  the  nails  in  children 
and  in  the  adult  (p.  389)  ; 
also  in  the  horny  epider- 
mis of  the  sole  of  the 
foot  (p.  399)  and  the 
palm  of  the  hand(p.  356). 
These  two  species  are 
not  accompanied  by  fol- 
licular inflammatory  reac- 
tion, which  is  seen  in 
other  forms  of  ringworm. 
(Kerion  of  Celsus,  p. 
158). 

The  hair,  in  all  inflam- 
m  a  t  o  r  y  trichophytons, 
shows  a  parasite  formed  of  mycelial  filaments  and  chains  of  spores. 
This  is  characteristic  of  trichophytons,  as  compared  with  the  ar- 
rangeiTient   of   irregularly   placed    small    spores    of    Microsporon 


Fig:.  86.     Trichcphvton    acuminatum.       (Culture    by 

Sabouraud.      Photo,     by     Noire.)      Culture     on 

gUxocised  gclose:   natural  size. 


196  THE    SCALP. 

Aiidouini.  But  in  the  inflammatory  trichophytons  the  parasite  is 
endo-cctothrix,  or  contained  within  the  hair  and  invading  the  folUcle 
around  it,  causing  inflammatory  folHculitis.  This  sign  is  character- 
istic of  trichophytons  of  animal  origin. 

TREATMENT    OF    RINGWORM. 

Prophylaxis.  This  treatment  includes  isolation  of  the  con- 
taminated patients.  This  isolation  is  relative;  but  the  disease 
being  very  contagious  for  children,  every  healthy  child  should 
be  removed  from  the  vicinity  of  one  affected  with  ringworm.  On 
the  other  hand  adults,  who  may  contract  only  a  circinate  vesic- 
ular erythema,  easily  curable  by  a  few  applications  of  iodine, 
may  remain  with  the  subjects  of  ringworm. 

Local  Prophylaxis.  A  patch  of  ringworm  being  capable  of 
indefinitely  inoculating  the  adjacent  healthy  scalp,  the  latter 
should  be  protected.  For  this  purpose  an  application  of  tincture 
of  iodine  (i  in  5  or  i  in  10)  should  be  made  every  night  to  the 
whole  scalp. 

Treatment  of  trichophytons  with  inflammatory  follicular  reac- 
tion. These  trichophytons  by  expelling  the  hair  and  causing  sup- 
puration of  the  follicle  are  practically  autophagons.  They  destroy 
themselves,  and  the  physician  has  only  to  attend  to  local  prophy- 
laxis and  treat  the  local  irritation.  For  this  purpose  all  the  hairs, 
living  or  dead,  on  the  surface  of  the  Kerion,  and  the  peripheral 
zone  of  healthy  hairs,  should  be  epilated  with  forceps;  after 
which  poultices  of  potato  starch  or  simple  moist  dressings  are 
applied.  Pure  tincture  of  iodine  is  contra-indicated,  but  it  may 
be  used  in  diluted  form  (i  in  10  or  i  in  15).  Experience,  however, 
shows  that  it  is  not  efficacious,  and  that  Kerion  treated  by  epila- 
tion, cleanliness  and  moist  dressings,  is  cured  in  the  least  time 
possible. 

TREATMENT    OF    RINGWORM    BY    THE   X-RAYS. 

This  method,  whenever  practicable,  should  be  employed  in 
preference  to  all  others.  The  apparatus  which  I  have  established 
at  the  Lailler  School  of  the  St.  Louis  Hospital  has  allowed  me  to 
form  regulations  for  the  use  of  the  X-rays  in  the  treatment  of 


THE   SCALP. 


197 


ringworm.  An  ordinary  current  supplies  a  dynamo  of  ^  horse 
power,  which  in  turn  suppHes  a  static  machine  with  12  plates. 
The  condensers  of  this  machine  collect  the  electricity  produced 
and  conduct  it  to  the  two  poles  of  a  Chabaud's  tube,  with  a 
Villars'  osmo-regulator.  A  Beclere's  spintermeter  is  interposed 
in  the  circuit,  which  measures  the  equivalence,  in  length  of  spark, 
of  the  internal  resistance  of  the  tube.  Lastly  on  each  wire  is 
placed  the  detonator  of  Destot  which  allows  the  resistance  of  the 
tube  to  be  increased  when  required.  The  tube  is  enclosed  in  a 
lantern  of  lead  foil  which  allows  the  X-rays  to  pass  only  by  a 
lateral  orifice.     Around  this  orifice  is  a  cylinder  to  limit    the 


Fig.  87.     Roots    of    healthy    hairs    from 
patch     of     ringworm     18     days     after 
radiotherapy.       (Preparation    by 
Sabouraud.      Photo,    by    Noire.) 


Fig.  88.     Ringworm       hairs        spontan- 
eously  expelled    20    days   afti^r   radio- 
therapy.     (Preparation    by    Sabour- 
aud.     Photo,    by    Nolr6.) 


emission  of  rays  to  a  single  useful  pencil,  and  to  fix  the  patient's 
head  at  a  fixed  distance  of  15  centimetres  (6  inches)  from  the 
centre  of  the  tube.  To  complete  this  preparation,  a  pastille  of 
platino-cyanide  of  barium  is  placed  at  a  distance  of  8  centimetres 
(3  1-5  inches)  from  the  centre  of  the  tube  at  a  fixed  point  of  the 
lantern. 

This  yellow  paper  becomes  brown  under  the  influence  of  the 
X-rays  and  acts  as  a  control  apparatus   (radiometer  X  of  Sabou- 


198 


THE    SCALP. 


raud  and  Noire).  The  sitting  is  then  terminated  and  the  scalp 
of  the  patient  has  received  the  quantity  of  X-rays  necessary  to 
cause  total  alopecia  of  the  region  exposed,  without  provoking 
erythema  or  radiodermatitis  and  without  preventing  restoration  later. 
A  patch  of  ringworm  is  thus  cured  at  a  single  sitting;  two 
patches  at  a  distance  from  each  other  in  two  sittings,  and  so  on. 
Sometimes  it  is  necessary  to  depilate  the  entire  head,  and  in 
this  case  the  parts  treated  are  covered  with  discs  of  lead,  to  avoid 
any  region  receiving  a  double  dose. 

To  depilate  the  entire  head  requires  12  successive  sittings,  which- 
are  of  8  to  13  minutes  w'ith  the  above  apparatus,  or  about  two  hours 
in  all.  The  hairs  fall  in  15  to  20  days  after  the  sitting,  and  on  the 
25th  day  the  roots  of  the  affected  hairs  are  expelled  spontaneously, 
still  containing  the  living  parasite.  On  the  30th  day  there  are  no 
traces  of  hair  or  of  parasite  on  the  patch,  and  the  child  is  bald,  but 
not  contagious.  The  hair  begins  to  grow  again  2^/2  months  after 
the  sitting  and  is  complete  in  5  months. 

Accidents.  If  the  time  limit  fixed  by  the  tint  of  our  radiometer 
is  exceeded,  whatever  the  kind  of  instrument  used,  there  is  danger  of 
radiodermatitis,  which  may  be  of  all  degrees,  from  erythema  lasting 

15  days,  up  to  scar- 
ring, which  may  per- 
sist for  several 
months.  All  radioder- 
matitis, even  when 
slight,  leads  to  perma- 
nent and  almost  com- 
plete alopecia  of  the 
scalp.  On  the  other 
hand  insufficiency  of 
time  causes  incom- 
plete depilation  and 
the  survival  of  dis- 
eased hairs.  This  ne- 
cessitates repetition  of 
the  treatment  and  in- 
creases the  chance  of 
incomplete  restoration 
of  haif. 

i'ig.  89.     Surface    exposed    30    days    after    radiotherapy.  AA/hf^n    two   mn<;pril- 

fSabouraud's   patient.     Photo,    by    Noirfe.)  VVUCU   ivvu  Li-iust^  u 


THE    SCALP.  199 

tive  applications  of  the  X-rays  are  made  without  precautions,  a 
spindle-shaped  space  receives  a  double  dose,  and  even  when  it 
only  shows  an  erythema  for  10  days,  the  hair  grows  badly  or  not 
at  all.  On  the  contrary,  when  two  adjacent  applications  do  not 
exactly  coincide,  bands  of  hair  remain  between  the  surfaces 
treated,  which  require  new  treatment.  The  X-rays  cause  a  tem- 
porary change  in  the  vitality  of  the  region  which  they  touch,  and 
it  frequently  happens  that  an  eruption  of  pustular  impetigo 
breaks  out  on  the  surfaces  exposed.  This  is  treated,  as  usual,  by 
applications  of  sulphur.  Finally  the  healthy  parts  must  be  pro- 
tected against  contagion  by  the  daily  application  of  tincture  of 
iodine   (i  in  5),  till  depilation  is  complete. 

FORMER   TREATMENT    OF    RINGWORM. 

When  the  necessary  apparatus  for  the  production  of  X-rays  is 
not  at  hand,  ringworm  may  be  treated  by  the  older  methods,  which 
include : — 

1.  Epilation,  repeated  every  15  days,  of  the  diseased  patches  and 
their  periphery. 

2.  The  daily  application  of  tincture  of  iodine  ( i  in  5 )  to  the  entire 
scalp  to  avoid  re-inoculation. 

3.  The  application  of  croton  oil,  every  10  days,  to  provoke  follicu- 
litis (which  is  the  same  as  causing  the  conditions  which  lead  to  the 
spontaneous  cure  of  Kerion).  But  this  method  leads  to  permanent 
cicatrices,  following  the  deep  suppurating  dermatitis  which  croton 
oil  produces  when  imprudently  used. 

By  these  methods,  and  by  slow  epilation  of  the  remainder  of  the 
diseased  hairs,  the  cure  of  ringworm  may  be  obtained  in  9  or  10 
months.  But  with  the  best  epilation  and  the  best  treatment  a  per- 
centage of  bad  cases  remain,  the  duration  of  which  is  unlimited. 

FAVUS. 

In  distinction  to  ringworm,  which  is  especially  an  urban  disease, 
favus  occurs  in  rural  districts.  It  may  occur  at  any  age.  In  the 
ordinary  form  the  disease  is  constituted  by  a  number  of  irregular 
but  clearly  defined  patches,  covered  with  sulphur  yellow  crusts,  like 
clay  in  colour  and  consistence.    The  crusts  are  circular  and  vary  in 


200  THE    SCALP. 

size,  the  largest  being  from  one  to  two  centimetres  and  showing 
circular  "waves."    These  are  the  "cups,"  the  smallest  of  which  form 


Fig.  90.     Favus    with    small    cups    after    epilation    of    the    scalp. 
(Besnier's    patient.      St.     Louis    Hosp.    Museum,     No.     548.) 

a  simple  ring  round  the  hair.  These  cups  are  transversed  by  the 
hairs  and  set  in  the  skin ;  they  may  be  detached  easily  in  pieces,  leav- 
ing an  apparently  deep  bleeding  surface.     The  duration  of  the  dis- 


THE  SCALP. 


201 


ease  is  indefinite,  the  lesions  extending  peripherally  and  causing 
re-inoculation  at  a  distance.  Eventually  they  are  incompletely  cured 
in  places  by  cicatrices.  Besides  the  cvip-shaped  form  there  are  two 
others ;  ( i )  pityriasiform,  somewhat  common,  in  which  the  patches, 
of  the  same  size  and  evolution  as  those  of  normal  favus,  present  no 
crusts,  but  a  chronically  red  surface  covered  with  adherent  squames ; 
(2)  an  impetiginous  form  of  the  same  character,  but  with  impeti- 
ginous, honey-like  crusts.  In  these  cases  diagnosis  must  first  be 
made  by  the  long  duration  of  the  disease  in  one  place.  All  patches 
of  chronic  evolution,  persisting  more  than  three  months  in  the  same 
place  should  suggest  favus. 

The  diagnosis  rests  on  the  character  of  the  hairs.  These  are  longer 
than  normal,  but  are  decolorised  for  a  centimetre  and  a  half  from 
the  base ;  for  this  extent  they  are  grey  and  have  lost  their  gloss.  The 
diagnosis  is  finally  certified  by  microscopic  examination  (p.  190). 
The  favus  hair  shows  a  mycelial  parasite,  composed  of  irregular 

flexible  filaments, 
not  numerous  and 
often  dead,  when 
their  course  is  in- 
dicated by  a  bub- 
ble of  air  of  the 
same  form.  The 
living  mycelial  fila- 
ments are  com- 
posed of  segments 
of  diflFerent  sizes 
and  shapes  and 
their  sporulating 
parts  are  subdi- 
vided by  trichoto- 
my and  tetrachoto- 
my.  The  cup  is  not 
a  crust,  but  an  ac- 
cumulation of  my- 
celium, more  regu- 
lar than  those  of 
me  hair.  The  culture  of  the  parasite  taken  from  the  cup  or  from 
the  hair  is  excavated,  yellow,  and  puflfed  up,  resembling  a  sponge. 
Human  favus  belongs  to  one  species  only,  the  two  other  specie"  of 


«*'v^ 


^Rjp-C 


:.,^^^iii>^ 


Fig  91.     Hair    from    favus:    enlarged    250    diameters. 
(Preparation  by  Bodin.     Photo,  by  Rothier.) 


202 


THE   SCALP. 


favus  described  are  found  only  in  animals  (mice  and  fowls,  etc.). 

The  treatment  of  favus,  according  to  Bazin,  consists  in  epilation 
by  forceps  repeated  for  5  or  6  months,  to  provoke  sterilisation  of  the 
hair  follicles. 

Depilation  by  radiotherapy  is  as  easily  carried  out  for  favus  as 
for  ringworm,  and  is  equally  curative,  but  in  a  fifth  of  the  cases  the 
cure  is  incomplete.  At  some  points  the  germs  survive  and  new 
cups  are  formed  on  the  skin,  while  the  hairs  have  not  had  time  to 
grow  again. 

Our  custom  at  the  Lailler  School  is  to  cause  epilation  by  radio- 
therapy first,  and  when  new  cups  appear  to  renew  the  application  to 
the  places  which  are  not  cured,  a  month  later. 

Favus  is  not  limited  to  the  scalp,  but  may  occur  in  all  regions  of 
the  body  and  on  the  nails  (p.  389). 

ALOPECIA  AREATA  IN  CHILDREN. 

This  was  admirably  described  by  Celsus  {De  re  medica),  who 
gave  it  the  name  of  apixTi^.    It  is  a  primary  alopecia,  not  preceded 


Fig.  92.     Club-shaped    Alopeclc    hairs. 

(Preparation     by     Sabouraud.     Photo. 

by    Nolr6.) 


Flgr.  93.     Alopeclc     hairs     mag- 
nified. 
(Preparation       by      Sabouraud. 
Photo,   by  Noire.) 


THE   SCALP. 


203 


by  any  functional  symptom,  excepting  rarely  some  degree  of  local 
pruritus.  The  hair  falls  either  dififusely  over  a  limited  region,  or 
more  usually,  in  areas  which  are  complete  from  the  first. 

This  area  may  be  median,  occupying  the  sub-occipital  fossa,  or 
lateral  and  roughly  symmetrical,  on  some  part  of  the  occiput.    The 

denuded  surface  is  ir- 
regular and  smooth.  It 
may  become  arrested 
and  undergo  resolution 
at  any  time;  on  the 
other  hand  it  may  in- 
crease and  denude  the 
whole  scalp  and  body. 
On  the  scalp,  areas  in 
process  of  extension 
are  indicated  by  the 
presence  of  the  charac- 
teristic hairs,  in  groups 
or  isolated. 

These  hairs,  which 
have  been  compared  to 
points  of  exclamation 
(!),  are  in  process  of  atrophy; 
they  resemble  a  piece  of  needle 
stuck  in  the  skin.  From  above 
downwards  they  diminish  in  size 
and  colour,  and  fall  out  more  or 
less  rapidly.  Areas  in  process  of 
restoration  are  indicated  by  the 
growth  of  fine  downy  colourless 
larger  and  pigmented  normal 
hairs,  which  are  succeeded  by 
hairs. 

On  the  alopecic  area  there  are 
often  dead  hairs  enclosed  in  the 
skin,  which  can  be  epilated  with- 
out traction;  or  black  punctiform 
debris  in  the  hair  follicles,  which 

Fig.  95.     Accumulations     of     corti- 
cal   cells    of    hairs    eliminated  (,^j-j  j^g  rcmOVCd  bv  SCraping.    (Fig. 
from    the    follicles.  -  f      &     \       t> 

(Preparation  ^^/j^.Sf^i^."^^'-^"'^-  95.)   Thls  dcbris  is  oftcu  mistaken 


Fig.  94.     Debris    of    atrophic    hairs    round    an 
alopecic   patch. 
(Preparation    by    Sabourard.     Photo,    by    Noir6.) 


^04 


THE   SCALP. 


for  a  new  growth  or  hair ;  on  the  contrary  they  are  hairs  in  process 
of  dissokition,  or  the  debris  of  dead  hairs. 

Alopecia  areata  of  the  nape  of  the  neck,  during  extension,  often 
becomes  cured  from  below  in  proportion  to  its  extent  above.  New 
patches  are  often  seen  at  the  margin,  which  coalesce  with  the  pri- 
mary patch  (arciform  alopecia).  At  other  times  it  is  prolonged 
above  both  ears,  denudes  the  temples,  and  joins  by  its  two  extremi- 
ties in  front.  On  the  other  hand,  the  process  may  be  reversed  and  it 
may  commence  by  a  large  frontal  notch  and  extend  from  before 
backwards,  or  become  limited  above  the  ears,  on  one  or  both  sides. 
In  any  case  the  alopecia  shows  a  remarkable  tendency  to  limit 
itself  to  the  borders  and  extend  round  the  head.     However,  even 

with  this  localisation  it  may  be 
accompanied  by  patches  of  all 
shapes  and  sizes  scattered  over 
the  scalp.  The  alopecia  which 
causes  total  baldness  usually  pro- 
ceeds in  this  manner. 

The  progress  of  the  disease  is 
always  slow,  but  very  variable. 
The  average  duration  is  about 
17  or  18  months  and  the  most 
favourable  cases  are  cured  in  3 
or  4  months.  Some  cases  are 
never  cured.  This  is  especially 
the  case  in  a  diffuse  retro-auricu- 
lar form,  which  always  remains 
diffuse  and  incomplete,  and  ter- 
minates by  absolute  disappear- 
ance of  the  affected  follicles.  In 
this  form  the  hair  cannot  be  restored  by  treatment.  In  other  forms, 
apparently  cured,  the  disease  may  recur  after  an  interval  of  5  or  15 
years.  It  is  sometimes  hereditary  and  consanguineous.  As  a  rule 
the  disease  does  not  appear  to  be  contagious.  This  disease  of  hairy 
localisation  seems  to  be  a  general  disease,  for  in  many  cases  the  nails 
show  traces  of  alteration.  The  cause,  in  my  opinion,  is  absolutely 
unknown ;  it  usually  begins  at  4  to  7  years  and  disappears  at  puberty; 
but  not  always,  for  some  cases  are  never  cured.  In  children  affected 
with  alopecia  areata,  want  of  tone  of  the  venous  system,  choreiform 
movements  and  excessive  adiposity  are  often  observed.     Excepting 


rig.  96.     Ophlaslc    Alopecia. 
(Sabouraud's  patient.     Photo  by  NoirS.) 


THE    SCALP. 


205 


alopecic  heredity,  which  I  have  observed  in  about  4  per  cent  of  the 
cases,  no  hereditary  taint  appears  to  be  common. 

The  treatment  is  unsatisfactory,  owing  to  the  etiological  uncer- 
tainty of  the  subject.    In  benign  cases  local  revulsion  appears  to  be 

of  use.  This  may  be  obtained 
by  many  methods ;  glacial  acet- 
ic acid,  I  in  40;  lactic  acid, 
20  per  cent;  ammonia,  10  per 
cent ;  liquid  blistering  agents 
followed  by  cauterisation  with 
nitrate  of  silver  (i  in  15).  All 
these  agents  may  be  employed 
with  frequent  success,  but 
without  absolutely  constant 
results. 

All  forms  of  treatment  have 
claimed  successes ;  sulphur 
baths,  external  tonics,  alco- 
holic frictions,  internal  ton- 
ics, etc.  These  may  be  pre- 
scribed according  to  circum- 
stances, after  careful  exami- 
nation of  the  patient,  but 
without  prejudice  or  previous 
theory.  The  X-rays  and  phototherapy,  especially  the  former,  have 
several  times  given  surprising  results,  such  as  re-growth  of  a  circle 
of  hair  in  the  middle  of  a  bald  area.  But  this  growth  is  only  tem- 
porary and  is  not  the  rule.  Alopecia  areata  still  waits  for  a  valid 
etiological  doctrine  and  a  rational  treatment. 


Fig:.  97.     Alopecia    areata    of    child. 
(Sabouraud's   patient.     Photo,    by   Nolr§.) 


THE    SCALP    IN    THE   ADULT. 


Pityriasis,  seborrhoea  and  the  so-called  seborrhoeic  eczema,  con- 
stitute a  morbid  group  which  includes  half  the  dermatoses  of  the 
scalp  occurring  between  the  ages  of  15  to  20  years  in  both  sexes. 

Ideas  on  these  subjects  are  so  confused  that  I  think  it  useful  to 
review  at  first  the  relationships  of  these  morbid  types,  in  a  special 
page.  We  are  not  concerned  here  with  controversial  opinions,  but 
with  clinical  observations. 


1.  At  10  or  12  years  of  age  the  heads  of  certain 

children  are  covered  zvith  pellicles  zvhich  per- 
sist during  several  years.  These  pellicles  are 
dry  and  the  condition  is  not  accompanied  by 
any  alopecia 

2.  From  14  to   18  or  16  to  20,  these  dry  pellicles 

seem  to  become  progressively  fatty  and  are 
accompanied  by  diffuse  alopecia,  zvith  changes 
in  the  ends  of  the  hairs 

3.  In  males  this  condition  is  the  second  stage  of  a 

clinical  scries  of  zvhich  the  third  is  seborrhoea 
decalvans  of  the  scalp.  The  pellicles  gradu- 
ally disappear  but  the  fatty  element  remains 
and  increases,  on  the  vertex:  the  alopecia 
increases,  becomes  localised  and  constitutes 
baldness  of  the  masculine  type 

4.  In  women  this  third  stage  occurs  rarely:  if  ends, 

as  in  men,  zvith  baldness  of  the  masculine 
type 

5.  Usually  women  reach  the  second  stage  and  re-' 

main  there.  They  retain  permanently  fatty 
pellicles  and  a  diffuse  paroxysmal  alopecia  of 
the  temporo-frontal  region,  sometimes  in 
bands  of  the  frontal  border  of  the  scalp   .    . 

6.  Chronic  pityriasis  is  formed  by  chronically  fused^ 

elements.  Originally  it  is  formed  of  distinct 
spots.  When  it  becomes  diffused  over  the 
scalp  it  preserves  this  form,  in  distinct  squa- 
mous patches,  which  may  or  may  not  be  com- 
plicated zvith  ecsematisation;  i.  e.  subsqua- 
mous  exudation.  This  seborrhoeic  eczema  is, 
by  Unna,  regarded  as  the  natural  develop- 
ment of  simple  or  steatoid  pityriasis,  and  the 
zvord  "seborrhoeic  eczema"  is  applied  by  him 
to  all  the  preceding  conditions 


Pityriasis  simplex  p.  207 


Pityriasis  s  t  e  a  - 
toides,  Alopecia 
pityrodes   ...   p.  208 

Trichoptilosis  .   .  p.  210 


Seborrhoea  decal- 
vans. Common 
baldness    .    .    .   p.  211 


Masculine       bald- 
ness in  women  p.  214 

Pityriasis     s  t  e  a  - 
toides  in  women  .  p.  214 
Frontal     Alopecia 
of  women 


Eczematisation   of 
pityriasis   ...   p.  215 


THE  SCALP  IN  THE  ADULT. 


207 


7.    Lastly,  in  certain  cases  the  exudation  is  profuse^ 
and  a  true  impetiginous  eczema  succeeds  the 
pityriasiform   conditions,   locally   or   remotely.\'Eczt.ma. 

ginodes 


impeti- 


-Eczema    sicca 


Alopecia  areata  in 
the  adult    .     .     . 


The    Hamburg    school    still    classes    most    of 
these   moist   eczemas   among   the   scborrhoeic 

eczemas 

Apart  from  these  morbid  forms  which  are  more' 
or  less  dependent  on  pityriasis,  a  dry  eczema  may 
occur  on  the  scalp,  differing  from  pityriasis,  in  its 

characters  and  microscopical  structure 

Psoriasis  in  all  its  forms  may  occur  on  the  scalp^ 
alone,  or  at  the  same  time  as  on  the  body  .     .    .     jPsoriasis 

Alopecia  areata  frequently  occurs  at  middle  age,' 
and  several  types  may  be  differentiated  which  we 
shall  study  separately;  many  others  cannot  be  dif- 
ferentiated and  we  shall  study   these  together  .    . 

IVe  shall  differentiate  from  alopecia  areata,  the 
cicatricial  permanent  alopecia  with  small  areas, 
known  in  France  as  the  pseudo-alopecia  areata  of 
Brocq 

We   shall   next   deal  with   lupus   erythematosus^^ 
u'hich  is  fairly  common  on  the  scalp,  where  it  pre 
sents    the   most   marked   atrophic   characters   .   . 

We  shall  say  a  few  7Vords  concerning  the  smalli]  lichen  planus 
raised,  chronic,  squamous  lesions,  ivith  cicatricialV  corneus  atro- 
evolution,  of  lichen  planus  corneus  atrophicus  .   .J     phicus    .    .     .     . 

After  this  we  shall  study  post-infectious  0/0-lPost-infectious  al- 
pecias,    in    general J     opecias   .     .     .     . 

.     .     .   and  syphilitic  alopecia,  together  with   the']  „     ,  .,. 
,.,..,.  ,  .  ,  ,,1  Syphilis 

other   syphilitic    lesions   zmich   may   occur   on    tlteV 

scalp J 


p.  216 


p.  216 


p.  217 


p.  219 


Pseudo-alopecia 
areata  of  Brocq.  p.  224 


Lupus    Erythe- 
matosus    .     .     . 


of      the 


p.  225 

p.  226 
p.  226 


Scalp 


p.  228 


PITYRIASIS  SIMPLEX. 

Pityriasis  simplex  is  a  chronic  dermatomycosis  of  the  scalp,  lim- 
ited to  continual  exfoliation,  dry,  and  without  redness  of  the  horny 
layer.  It  is  associated  with  the  constant  presence  of  the  cryptogamic 
parasite  known  as  the  Spore  of  Molasses  (1874)  and  incorrectly 
under  the  name  of  the  hottle-bacilhis  of  Unna  (1892).  This  para- 
site occurs  plentifully  in  all  the  squames  of  pityriasis. 

Pityriasis,  which  always  appears  to  arise  by  distinct  squamous 
patches,  remains  afterwards  dififuse.  It  is  formed  of  more  or  less 
fine  powdery  or  lamellar  squames,  which  are  easily  detached  from 


2o8  THE  SCALP  IN  THE  ADULT. 

the  horny  epidermis  and  fall  on  the  clothes.  This  condition  is  accom- 
panied by  slight  itching,  more  marked  during  sweating.  There  is  no 
alopecia.  "So  long  as  the  squames  of  pityriasis  fall,  the  hairs  do 
not  fall." 

This  condition  is  very  tenacious ;  treatment  removes  it,  but  it 
recurs.  In  the  course  of  time  it  is  transformed  locally  into  alopecic 
pityriasis  with  apparently  fatty  squames,  which  we  shall  study 
shortly.     In  rare  cases  the  pityriasis  remains  dry  for  life. 

Active  treatment  only  gives  temporary  benefit.  The  following 
ointments  may  be  applied  every  night  and  washed  off  in  the 
morning : — 

(i)  Oil  of  Cade lo  grammes        ^  fs 

Ichthyol 1 

Resorcme r   aa     i  gramme       gr.  24 

Oil  of  birch j 


Lanoline 20  g-rammes 


oJ 


(2)  Oil  of  Cade 10  grammes        5  fs 

Pyrogallic  acid 


-   aa     I    gramme     gr.  24 


Yellow   oxide   of 

Mercury       .  .... 

Resorcine 

Lanoline 20  grammes  ^J 

Together  with  the  active  remedies,  weaker  preparations  may  be 
used  as  hygienic  measures : — 

(i)   Sulphide  of  potash  .... 

Distilled  water 

Spirit  of  lavender  .... 
Bichloride  of  Mercury  .  . 
Coal  tar  (saponified)  .  . 
Alcohol,  60  per  cent  .  . 
Glacial    acetic    acid    .     .     . 


I  part 

303  parts 

25  grammes 

5j 

30  centigrammes 

gr.Vi 

25  grammes 

3j 

250 

Bi 

S  drops 

mj 

PITYRIASIS  STEATOIDES.     ALOPECIC  PITYRIASIS. 

In  the  adult,  usually  towards  the  15th  or  i6th  year,  the  squames 
of  pityriasis  become  thick  and  yellow  and  leave  a  grease  spot  on 
blotting  paper.  This  condition  renders  them  less  easily  detached 
and  they  remain  on  the  scalp.  "They  fall  no  more,  but  then  it  is 
the  hairs  which  fall."  The  hairs  fall  off  more  and  more;  at  first 
in  the  summer,  but  afterwards  at  all  seasons ;  sometimes  in  bunches, 
sometimes  gradually.  In  this  way  is  constituted  pellicular  alopecia, 
which  in  the  adolescent  is  a  premonitory  stage  of  baldness  in  women, 


THE    SCALP    IN    THE    ADULT. 


209 


the  forerunner  of  chronic  recurrent  diffuse  alopecia.  Steatoid  pity- 
riasis occurs  diffusely  on  the  vertex  and  the  temples,  as  far  as  the 
retro-auricular  regions,  where  it  often  forms  isolated  patches.  The 
functional  symptoms  are  limited  to  more  or  less  marked  itching 
and  alopecia. 

The  hair  which  falls  comes  out  entire  with  bulbs  in  the  form  of  a 
turnip.  They  have  a  tendency  to  be  replaced  by  new  hairs,  which 
in  untreated  cases  also  fall  out. 

The  treatment  of  steatoid  pityriasis  is  the  same  as  that  of  the  dry 
])ityriasis.  The  more  fatty  the  scales,  the  more  sulphur  is  added  to 
the  oil  of  cade  ointments.  Fatty  pityriasis  should  be  treated  actively 
for  several  weeks,  followed  by  lotions  to  keep  the  head  free  from 
fat.  The  alopecia  ceases  with  the  fatty  condition  of  the  surface,  and 
returns  with  it.  This  condition  persists  in  women  during  life,  with 
a  maximum  of  the  pellicular  condition  towards  20  or  25  years  and 
a  maximum  fall  of  hairs  at  25  to  35  years.  In  men  there  is  usually 
an  intermediate  stage  between  dry  pityriasis  and  seborrhoea,  between 
the  15th  and  i8th  years. 

ALOPECIA  PITYROIDES. 

This  alopecia  is  paroxysmal  and  the  result  of  the  preceding  form 
of  pityriasis.  It  occurs  at  first  every  year  in  the  summer;  then 
begins  earlier  and  ends  later,  finally  becoming  continuous,  with 
exacerbations  coinciding  wnth  temporary  increase  in  the  fatty  state 
of  the  skin  and  hair.  This  condition  is  transitory  in  men  and  precedes 
seborrhoea.  In  women,  who  only  exceptionally  become  bald,  it  is  a 
permanent  condition.  Thus  at  about  the  twentieth  year  women  are 
divided  into  two  categories;  those  who  never  lose  their  hair  and 
those  who  constantly  lose  too  much. 

This  alopecia  is  always  diffuse,  but  more  marked  on  the  temples 
and  forehead.  It  never  ends  in  making  a  region  completely  bald, 
but  renders  the  hair  more  and  more  scanty. 

All  treatment  removing  fat  is  useful  in  these  cases ;  soap,  lotions 
of  sulphur  and  ether,  ammonia,  etc.,  arrest  or  considerably  diminish 
the  fall  of  hair  and  favour  the  new  growth  which  has  a  tendency  to 
establish  itself. 

1.  Wash  once  or  twice  a  month  with  sulphur  or  oil  of  cade  soaps 
or  with  sulphur  lotion. 

2.  Daily  friction  by  means  of  a  brush,  with  either  of  the  fol- 
lowing : — 

14 


210 


THE    SCALP    IN    THE    ADULT. 


(i)   Hoffmann's    liquor  .  . 

Spirit  of  lavender  .  .  . 

Distilled   water    .    .  .  . 

Nitrate  of  potash   .  .  . 

Liquid   Ammonia    .  .  , 

(2)  Acetone 

Coaltar    (saponified) 
Tincture  of  quillaia   . 
Spirit  of  lavender  .    . 
Distilled   water    ... 
Hydrochlorate   of  pilo- 
carpine     


} 


225  grammes  3J 

25          "  3? 

50          "  5ii 

50  centigrammes  gr.  j 

4  grammes  gr.  8 

200  grammes  5J 

25  grammes  3j 

25  grammes  3j 

50  centigrammes  gr.  j 


This  form  of  treatment,  when  long  continued  and  modified  accord- 
ing to  the  form  and  degree  of  the  alopecia,  gives  good  results,  but 
requires  patience. 

TRICHOPTILOSIS.      TRICHORRHEXIS. 

I  shall  only  say  a  few  words  concerning  a  very  common  lesion  of 
the  hair,  as  v/ell  as  trichorrhexis  nodosa  (p.  144)  occurring  in  the 
scalp  of  women  affected  with  pityriasis  and  pityroid  alopecia.    This 


Figr.  98.     Hair   affected   with    trlchoptlllosls. 
((Sabouraud's    preparation.     Photo,    by    Noirf.) 

is  trichoptilosis,  which  is  too  well  represented  in  the  figure  to  require 
any  further  description.    The  hair  resembles  a  quill  pen. 

In  trichorrhexis  the  hair  presents  near  its  extremity  the  nodes 
which  we  have  described  in  the  moustache.  These  lesions  are  gen- 
erally caused  by  the  too  frequent  use  of  soap. 


THE    SCALP    IN    THE    ADULT. 
SEBORRHOEA    DECALVANS.      BALDNESS. 


Seborrhoea  of  the  scalp,  as  in  all  other  situations,  is  not  a  pellicular 
disease,  but  a  hypersecretion  of  sebaceous  fat.  Its  objective  symp- 
tom and  elementary  lesion  is  a  cylinder  of  fat 
contained  in  the  sebaceous  duct,  which  may  be 
pressed  out  in  the  form  of  vermicular  mass,  the 
rudiment  of  the  comedo.  This  fatty  cylinder  is 
the  habitat  of  a  colony  of  micro-organisms 
formed  exclusively  by  the  seborrhoeic  microbacil- 
lus,  the  presence  and  species  of  which  are  con- 
stant and  characteristic. 

The  affection  begins  on  the  face  and  extends 
^       Its  extension  is  syn- 
chronous with  the  commencement  and  develop- 
ment of  the  alopecia  which  causes  common  baldness  in  men;  early 


Fig.  99.       Medal       of 
which  the  name  of 

-.ifp^pS^b/m-'^to  the  forehead  and  scalp. 


'Fig.  100.     Seborrhoea    decalvans.     Common    baldness. 
(Sabouraud's   patient.     Photo,    by   Noir6. ) 

or  late.     This  disease  generally  follows  a  fatly  pityriasis,  which  it 
gradually  supplants.     Hence,  seborrhoea  causing  baldness  appears 


THE    SCALP    IN    THE   ADULT. 


clinically  as  the  third  stage  of  a  disease,  the  first  two  stages  of  which 
were  pityriasis  simplex  and  pityriasis  steatoides. 

The  alopecia  of  seborrhoea  is  much  less  diflfuse  and  intense  than 
that  of  pityriasis,  and  as  a  rule  the  younger  the  subject  the  quicker 
the  progress.  When  it  commences  at  18  it  causes  baldness  at  25, 
with  a  fall  of  three  or  four  hundred  hairs  daily.  When  it  commences 
at  25  it  only  ends  in  incomplete  baldness  at  about  55  or  60,  with  a 
loss  of  30  to  60  hairs  a  day,  varying  according  to  season. 

The  hairs  fall  out  entire  with  their  bulbs.  They  are  reproduced 
by  hairs  which  fall  in  their  turn,  each  growth  being  slower  or  more 

scanty,  till  there  is  nothing 
but  a  downy  growth  on  the 
scalp. 

Sometimes  seborrhoea,  in- 
stead of  replacing  pityria- 
sis, co-exists  with  it  and 
forms  a  clinical  picture,  in- 
correctly named  squamous 
seborrhoea.  It  is  really  a 
mixed  process,  a  super- 
seborrhoeic  pityriasis. 

The  treatment  of  bald- 
ness gives  mediocre  re- 
sults, but  not  none  at  all, 
as  many  think.  The  cure 
of  baldness  does  not  exist 
in  the  sense  of  restoring 
the  hair  completely,  but 
treatment  of  a  seborrhoeic 
scalp  may  retard  for  many 
years  a  baldness  in  process  of  extension. 

The  treatment  varies  according  to  the  form  and  age  of  the  disease 
and  the  toleration  of  the  skin  for  useful  medicaments.  The  squamous 
element  must  first  be  treated,  when  this  exists,  by  sulphur  or  oil  of 
cade  ointments,  applied  at  night  and  washed  oflf  in  the  morning: — 

Lanoline T 

■  |-  aa     10  grammes      5j 
•J 


Figr.  101.     Typical   baldness   ciu3   to   Seborrhoea 
decalvans.      (Sabouraud's  patient.) 


Vaseline 

Oil  of  Cade 

Oil  of  birch 

Turpeth    mineral ^  aa 

Precipitated    Sulphur    .    .    . 


I  gramme  gr.  5 


THE    SCALP    IN    THE   ADULT.  213 

This  clears  up  the  pityriasis  and  greatly  diminishes  the  fall  of  hair. 
It  should  be  followed  by  repeated  soaping  every  night  to  remove 
the  sebaceous  exudation,  the  stagnation  of  which  appears  to  be  toxic 
for  the  hair;  and  by  friction  in  the  morning  by  lotions,  of  which 
the  following  are  examples: — 

(i)    Ether      200  grammes         3j 

Alcohol,  96   ner   cent 50          "             5  ii 

Tincture  of  Jaborandi  .    .    .    .   t  ,, 

Coaltar  (saponified) |  aa     25                           -J 

Liquid  Ammonia 5           "         m.  xii 

(2)  Absolute    Alcohol 200  grammes  5J 

Tincture  of  Capsicum 20         "  -i  _. 

Spirit  of  rosmary 30         "  j  ^■^ 

Sal  Alembroth 30  centigrammes  gr.  j 


(3)   Distilled    water  . 

Nitrate  of  potash 

Nitrate  of  pilo-   . 

carpine    .    .    . 


Fig.  102.     Common    baldness. 

.    .  50  grammes  jj 

aa     50  centigrammes  gr.  5 


214  THE    SCALP    IN    THE    ADULT. 

In  cases  where  the  sebaceous  secretion  is  intense,  more  active 
treatment  is  required,  with  a  basis  of  sulphur.  These  may  be  appHed 
as  powders  or  lotions. 


(i)   Precipitated    Sulphur 
Dried    oatmeal     .    .    . 


|-  equal  parts 


(2)  Alcohol,  60  per  cent 20  grammes     3ii 

Precipitated    Sulphur 10         "  Jj 

Rose  water 70        "  Jj 

(3)  Sulphide  of  Carbon  saturated  with  Sulphur  (this  is  very  inflam- 

mable and  causes  smarting). 

By  these  measures,  varied  according  to  the  results  obtained,  the 
intensity  of  the  disease  may  be  diminished  by  half  or  two-thirds,  but 
in  most  cases  without  arresting  it  completely.  However,  a  delay  of 
5  to  15  years  in  the  evolution  of  baldness  may  be  considered  to  be  a 
satisfactory  result  in  the  case  of  a  disease  which  cannot  be  cured 
absolutely. 

BALDNESS  OF  THE  MASCULINE  TYPE  IN  WOMEN. 

This  occurs  in  women  between  the  ages  of  20  and  30,  who  at 
about  the  15th  year  have  had  a  hypertrichotic  attack  of  intense  pity- 
riasis. In  these  subjects,  who  often  have  the  shade  of  a  moustache 
and  excessive  development  of  the  body,  baldness  occurs  with  exactly 
the  same  symptoms  and  the  same  evolution  as  in  men,  and  when  left 
to  itself  has  the  same  prognosis ;  progressive  and  irremediable  denu- 
dation of  the  vertex.  In  women  baldness  is  to  be  treated  in  the 
same  way  as  in  men  and  generally  produces  better  results. 

As  in  men,  the  disease  at  the  ages  of  30  to  35  gradually  becomes 
less  intense  and  progresses  more  slowly ;  but  at  this  time  the  patient, 
with  short  hair,  will  have  the  appearance  of  a  man  three  parts  bald. 

FRONTAL  SEBORRHOEIC  ALOPECIA  IN  YOUNG  GIRLS. 

In  young  girls,  between  the  ages  of  15  and  18,  at  the  time  when 
polymorphous  acne  of  the  face  occurs,  and  in  constant  co-existence 
with  this  morbid  type,  there  appears,  on  the  frontal  border  of  the 
scalp,  a  mixture  of  pityriasis,  seborrhoea  and  polymorphous  acne 
with  small  elements,  the  whole  disposed  in  a  band  about  an  inch 


THE    SCALP    IN    THE   ADULT.  2iS  - 

wide,  taken  at  the  expense  of  the  front  of  the  scalp  and  extending 
from  one  ear  to  the  other.  We  have  already  spoken  of  this  form  of 
alopecia  in  studying  the  frontal  region  (p.  122). 

The  treatment,  if  the  case  is  seen  at  the  time  of  appearance  of  this 
local  seborrhoea,  is  that  of  all  forms  of  acne;  sulphur  lotion  and  oint- 
ment : — 

Precipitated   Sulphur     .    .    . 

Ichthyol [      aa     I  gramme     gr.  16 

Resorcine       

Oil  of  Cade 


5         "  3i  fs 


Lanoline 3°        '  5j 

This  is  cleaned  oft"  in  the  morning  with  absorbent  wool  moistened 
with  Hoffmann's  solution.  The  treatment  requires  perseverance. 
More  commonly  the  lesion  is  already  of  old  standing  when  first 
seen  and  treatment  has  no  effect. 

EXTENSIVE  PITYRIASIS.    "SEBORRHOEIC  ECZEMA." 

In  a  certain  number  of  cases  steatoid  pityriasis  of  the  scalp  takes 
on  unusual  development,  extending  beyond  the  hair  for  about  half 
an  inch  in  the  form  of  yellow  fatty  scales,  situated  on  a  red  base. 
(Corona  Seborrhoica.)  This  is  a  dermatological  type  of  adoles- 
cence especially  common  in  women.  The  eruption  may  extend  over 
a  large  part  of  the  body,  on  the  seborrhoeic  regions,  i.e.,  in  the 
natural  folds,  the  groins,  axillae  and  mid-sternal  region ;  on  the 
face,  in  the  naso-genial  furrow,  the  suprasuperciliary  regions  and 
eyebrows,  moustache,  beard,  ear,  etc.  The  lesions  are  at  first 
covered  with  fatty  scales,  and  become  slightly  exudative  under  the 
crusts  by  numerous  minute  orifices,  hardly  visible  by  a  lens.  These 
are  open  histological  vesicles,  constituting  eczematisation  (p.  561). 
These  cases  may  be  thus  explained  as  an  eczematisation  arising 
underneath  a  steatoid  pityriasis  with  florid  development ;  eczematisa- 
tion being  one  of  the  most  common  of  the  cutaneous  reactions  to  all 
morbid  or  therapeutic  irritations. 

Treatment  gives  rapid  and  excellent  results,  and  a  cure  is  generally 
obtained  in  3  to  6  weeks  in  the  most  favourable  cases.  These  cases 
are  divided  into  two  groups. 

If  the  skin  is  strong,  sulphur  and  mercurials  are  indicated: — 


2i6  THE    SCALP    IN    THE   ADULT. 

,  Cinnabar i  gramme       gr.  i6 

Precipitated  Sulphur 3  grammes     gr.  48 

Vaseline 30         "  5j 

If  the  skin  is  sensitive  tar  preparations  are  good: — 

Oil  of  Cade 10  grammes     5ii  fs 

Ichthyol ~| 

Resorcine r   aa       i   gramme       gr.  16 

Oil  of  birch J 

Lanoline 30  grammes      jj 

In  doubtful  cases  ointment  of  both  types  may  be  tried,  but  with 
small  doses  and  on  limited  areas.  The  patient  continues  the  treat- 
ment with  that  which  succeeds  best.  The  prognosis  of  this  affection 
is  generally  good,  but  it  may  recur.  Occasionally  cases  commence 
in  the  same  way,  but  evolve  towards  the  type  of  more  or  less  chronic 
or  severe  dermatitis  (p.  590). 


IMPETIGINOUS    ECZEMA. 

Cases  occur  which  begin  like  the  preceding,  but  evolve  towards 
a  clinical  type  which  is  much  more  exudative  and  crusted.  The  scalp 
is  soon  passed  by  and  the  exudation  extends  to  the  ears,  cheeks,  etc. 
This  occurs  usually  in  young  people  of  a  chlorotic  type.  Dimin- 
ished acidity  of  the  urine  and  albuminuria  should  be  looked  for,  and 
the  general  condition  treated  (p.  12). 

Local  treatment  by  nitrate  of  silver  ( i  in  15)  and  protective  pastes, 
gives  variable  results,  as  in  the  same  morbid  type  in  the  child.  Mild 
tar  ointments,  similar  to  those  employed  in  the  preceding  clinical 
type,  also  give  good  results.  These  clinical  types  require  several 
therapeutic  attempts.  I  have  often  seen  good  results  from  a  cure  at 
St.  Gervais,  when  the  lesion  was  pruriginous ;  and  at  St.  Xectaire, 
when  there  was  evidence  of  albuminuria,  even  intermittent ;  ortho- 
static or  digestive. 

DRY    ECZEMA. 

Eczema  of  the  scalp  is  always  characterised  by  not  limiting  itself 
to  the  hairy  regions,  and  disregarding  their  boundaries.  The 
squames  of  dry  eczema  are  of  two  kinds;  the  one  fine,  powdery, 
micaceous,  uniform,   forming  large  parietal    placards,    the    vertex 


The  scalp  in  the  adult.  217 

remaining  free ;  the  other,  papyraceous  and  yellow,  having  a  slight 
tendency  to  serous  exudation,  which  soon  becomes  hardened.  The 
second  type  causes  the  false  tinea  amiantacca  of  Dcvcrgie  (p.  i8o). 
which  appears  to  be  only  a  form  of  eczema. 

This  eczema  differs  microscopically  from  pityriasis  in  the  fact 
that  the  squames,  on  bacteriological  examination,  show  no  flora  what- 
ever and  no  spores  of  Malasscz. 

The  treatment  of  these  eczemas,  like  that  of  many  affections  char- 
acterised by  hyperkeratosis  and  dyskeratinisation,  consists  in  mild 
applications  of  tar  applied  at  night  and  washed  off  in  the  morning 
with  superfatted  soap  and  a  badger  hair  brush : — 


Oil  of  Cade ^ 

r\     A        c  7-  f      «ia       5  grammes  Ji  is 

Oxide  of  Zinc J  -^ 


Oil  of  Cade 
Oxide  o 

Lanoline 

Vaseline J  -^ 

Ichthyol 1 

Resorcine r     aa       i  "  gr-  i6 

Oil  of  birch -' 

The  prognosis  of  these  forms  of  eczema  is  usually  good,  and  the 
cure  rapid. 

PSORIASIS. 

Psoriasis  may  be  confined  exclusively  to  the  scalp,  but  this  is  rare. 
Even  in  cases  where  it  is  at  first  apparently  limited  to  the  scalp,  there 
is  more  often  found  an  isolated  patch  on  the  elbow,  knee,  abdomen 
or  penis,  which  confirms  the  diagnosis. 

The  characters  of  the  patch  of  psoriasis  are  the  same  on  the 
scalp  as  elsewhere.  It  is  a  dry  scaly  patch  with  adherent  chalky- 
scales,  the  removal  of  which  seldom  removes  any  of  the  hairs 
which  transverse  it,  and  exposes  the  red  epidermis  which  is  soon 
covered  with  fine  h?emorrhagic  points. 

The  patch  may  be  from  less  than  half  an  inch  to  six  inches  in 
diameter,  but  is  never  of  large  size  without  the  co-existence  of 
psoriasis  of  the  body.  In  the  case  of  generalised  psoriasis  the 
squamous  patches  are  confluent  and  may  cover  the  entire  scalp 
to  a  thickness  of  half  an  inch.  The  hairs  preserve  their  number 
and  transverse  the  crust  as  if  it  did  not  exist.  Psoriasis  of  the 
scalp  has  the  same  prognosis  as  psoriasis  of  the  body.  It  is 
liable  to  frequent  recurrence,  but  the  recurrences,  here  as  else- 


2i8  THE    SCALP    IN    THE   ADULT. 

where,  are  due  to  absence  of  care  and  perseverance  in  treatment. 

Finally,  psoriasis  of  the  scalp  is,  as  a  general  rule,  an  epiphe- 
nomenon  in  the  course  of  psoriasis  of  the  body. 

But  a  series  of  lesions  exists,  psoriasiform  in  size  and  appear- 
ance, the  crusts  of  which  appear  to  be  more  fatty  than  those  of 
ordinary  psoriasis.  Clinically,  these  cases  and  their  varieties 
connect  true  psoriasis  with  the  figured  and  nummular  forms  of 
steatoid  pityriasis  with  florid  development.  This  uninterrupted 
chain  has  given  rise  to  the  most  controversial  explanations  and  to 
the  identification  of  ordinary  psoriasis  with  pityriasis,  under  the 
name  of  "seborrhoeic  eczema." 

These  questions  are  settled  by  the  microscope,  which  shows 
that  most  of  the  "psoriasiform  seborrhoeic  eczemas"  or  "psoriasi- 
form seborrhoeids"  have  crusts  of  which  the  histological  structure 
is  that  of  true  psoriasic  crusts,  and  also  that  they  do  not  possess 
the  special  flora  of  pityriasis.  They  are  cases  of  artificial 
psoriasis. 

The  classical  treatment  of  psoriasis  is  by  tar.  When  the 
crusts  are  dry  and  thick  and  the  lesions  chronic,  mordants  are 
added  to  the  tar,  such  as  pyrogallic  acid  or  chrysarobin.  When, 
on  the  contrary,  the  crusts  are  fatty,  sulphur  is  added  to  the  oint- 
ment. 

STRONG    OINTMENT. 
La"°''"^ \     aa     20  grammes  aa     5  f s 


Oil  of  Cade  . 
Pyrogallic  acid  .  . 
Chrysarobin  .  .  .  . 
Turpeth  mineral   . 


aa       I  gramme  aa     gr.  24 


MEDIUM    OINTMENT. 

Lanoline 3°  grammes  3J 

Oil  of  Cade 10  "  5ii  fs 

Yellow  oxide  of  Mercury  .  1 

Resorcine >^  ^  "  S:r.  16 

Pyrogallic  acid 75  centigrammes  gr.  12 

MILD  OINTMENT. 

Oil  of  Cade 10  grammes  5ii  fs 

Lanoline 3°  "  5} 

Resorcine 1 

Ichthyol I  aa     I  "  gr.  16 

Oil  of  birch 


THE    SCALP    IN    THE   ADULT.  219 

OINTMENT  FOR  PSORIASIS   WITH   FATTY   CRUSTS. 

Oil  of  Cade 10  grammes  5ii  fs 

Lanoline 30  "  5j 

Ichtliyol -| 

Resorcine I  aa       i  gramme  gr.  16 

Oil  of  birch   . J 

Cinnabar  T 

Precipitated  Sulphur  .    .    J   ^''^       '  gramme  gr.  16 

No  internal  treatment  of  psoriasis  gives  appreciable  results. 

ALOPECIA  AREATA  IN  THE  ADULT. 

Alopecia  areata  is  one  of  the  dermatological  subjects  which  still 
remains  obscure.  I  shall  divide  this  chapter  according  to  the  facts 
of  my  clinical  experience. 

a.  Alopecia  areata  in  hereditary  syphilis.  There  is  an  alopecia 
areata  of  old  syphilitics  and  of  heredo-syphilitics.  In  the  latter  case 
it  commences  about  the  20th  year,  sometimes  as  a  recurrence  after 
benign  alopecia  of  childhood.  The  patient  usually  presents  distinct 
stigmata  of  hereditary  syphilis;  dental  dystrophies  (Hutchinson's 
teeth,  striated,  pitted,  deformed  teeth ;  molars  with  crowns  deprived 
of  dentine,  etc.),  arched  palate,  prognathism  of  the  lower  jaw,  con- 
cave profile,  crescent  shaped  head,  natiform  skull,  dwarfism,  deaf- 
ness by  tympanic  ossification,  interstitial  keratitis,  sabre  shaped  tibia, 
etc.  Family  history  records  miscarriages,  stillbirths,  children  dying 
of  convulsions  in  infancy,  and  the  subject  is  often  the  first  survivor 
after  several  stillbirths.  The  father  is  sometimes  found  to  have 
died  of  tabes ;  progressive  muscular  atrophy  or  epilepsy  at  about 
the  age  of  50. 

This  disease  is  usually  severe  and  may  cause  the  loss  of  all  the 
hair  and  aflfect  the  nails.  Usually  it  takes  the  form  of  permanent 
alopecia  (E.  Besnier),  with  continual  recurrences  and  partial  re- 
growth.  Treatment  appears  to  be  useless,  both  local  and  general ; 
even  antisyphilitic  treatment,  which  I  have  never  been  able  to  carry 
out  sufficiently,  owing  to  the  patients  not  understanding  the  reason. 

b.  Alopecia  areata  of  Chronic  Tuberculosis.  There  is  certainly 
an  alopecia  of  chronic  pulmonary  tuberculosis.  Like  the  pre- 
ceding form  it  is  of  fairly  frequent  occurrence. 

It  always  co-exists  witli  tubercle  of  the  apex,  known  or  unknown, 
but  recognisable,  and  appears  due  to  compression  of  the  superior 


THE    SCALP    IN    THE    ADULT 


thoracic  sympathetic  ganglion  by  pleural  adhesions  (lacquef).  It 
seems  that  this  is  more  an  adjacent  inflammation  than  a  compression 
of  the  ganglion  by  fibrosis,  for  the  alopecia  is  cured  with  the  pul- 


Fiic  103      Nearly  total  alopecia  in  a  dwarf  presenting  all  the  stigmata  of  heredl- 
*■         ■  tary   syphilis.      (.SabourauU's   patient.     Plioto.    by   Noir6.) 

monary  tuberculosis  and  varies  with  its  fluctuations.  It  is  often 
cured  incompletely.  This  alopecia  has  the  form  of  ophiasis  of  chil- 
dren, occipital  and  circumferential.  It  is  often  accompanied  by 
amorphous  alopecic  patches,  disseminated  over  the  scalp,  but  more 
frequent  on  the  occipital  region. 


THE    SCALP    IN    THE   ADULT.  221 

The  treatment  is  that  of  tuberculosis,  to  which  may  be  added  local 
revulsion,  which  is  of  doubtful  value  in  these  cases. 

c.  Alopecia  areata  of  the  menopause  or  period  of  involution. 
In  men  or  women  of  about  50  years  of  age,  with  hair  becoming  grey, 


Fig.  104.     Alopecia  of  right  arm   in   a  case  of  alopecia  with  continual   recurrence-. 
(Sabouraud's   patient.     Photo,   by  NoirS. ) 

there  is  occasionally  observed  an  alopecia  in  amorphous  patches, 
varying  in  number  and  size,  occupying  the  parietal  and  lateral  frontal 
regions  and  sometimes  the  occiput,  but  generally  without  any 
regional  election. 

This  alopecia  avoids  relatively  the  white  hairs  on  the  alopecic 
areas.  The  evolution  takes  7  or  8  months  and  progressive  retro- 
gression about  the  same  time.  It  is  generally  completely  cured  in 
18  months.    Its  cause  is  unknown  and  treatment  consists  in  correct- 


THE    SCALP    IN    THE    ADULT. 


ing  everything  which  is  defective  in  the  subject;  for  instance,  ova- 
rian opotherapy  in  women,  etc.  Local  treatment  consists  in  revul- 
sion, the  effect  of  which  is  slow  and  uncertain. 

d.  Alopecia  areata  of  unknown  origin.  This  forms  the  grea:t 
majority  of  cases.  Sometimes  it  begins  in  round  patches,  with  a 
fatty  surface  from  seborrhceic  infection,  which  may  extend,  multiply 
and  coalesce.  The  evolution  may  be  benign  or  severe,  and  may 
become  general,  ending  in  total  baldness.  Benign  cases  may  recr.r 
sooner  or  later  after  the  first  attack,  with  the  same  or  difTerert 
severity. 

Benign  alopecias  present  one  or  two  alopecic  patches,  the  exten- 
sion of  which  ceases  after  3  or  4  weeks,  and  in  which  the  re-growth 
of  down  and  normal  hairs  occurs  quickly.  Severe  alopecias  form 
large  patches,  slow  or  rapid  in  evolution.  They  are  accompanied  b>" 
more  or  less  marked  flaccidity  of  the  skin  (hypotonus  of  Jacquet) 
with  a  progressive  senile  appearance.  Lesions  of  the  nails  are  seen 
in  about  a  third  of  the  cases  (p.  388). 

There  is  no  theory  which  explains  alopecia  areata  in  the  adult  any 
more  than  in  the  child.     x\lopecia  areata  in  tuberculous  subjects 
may  only  be  explained  by  means  of  a  hypothesis  which  is  not  yet 
verified.    Its  occurrence  in  the  subjects  of  heredo-syphilis  is  a  mat- 
ter of  observation,  the  mechanism 
of  which  is  unknown.     All  other 
forms  are  still  more  inexplicable. 
The  theory  of  the  neuralgic  and 
dental    origin    of   alopecia    areata 
{Jacquet)   is   possibly  applicable 
to  certain  cases,  which  I  think  are 
rare ;  for  a  greater  number  of  se- 
vere cases  of  alopecia  are  accom- 
panied by  onychosis.     It  is  diffi- 
cult to  admit  onychosis  of  dental 
origin,  especially  on  the  feet.     It 
is  probable,  by  comparison  of  se- 
vere and  benign  cases,  that  alo- 
pecia areata  not  accompanied  by 
_.    ,„^  „  ^        „     ,,..      ..„      onvchosis  owes  the  absence  of  this 

Pig.  105.  Tegumentary    flaccidity:    "Hy- 
potonus" of  Jacquet.  in  total  alopecia.      c-i-mr>fr»m     fn     ifc     Kpnio-nit\'         TVlP 
(Sabouraud's  patient.  Photo,  by  Noire.)     S>  mptOm    tO     ItS     Demgmt}  .        i  ne 


THE    SCALP    IN    THE    ADULT.  "  223 

seborrhcEic  infection  of  certain  cases,  especially  those  accompanied 
by  hypotonus,  is  certain,  but  the  factor  of  this  infection  in  the  gene- 
sis of  alopecia  areata  has  not 
yet  been  proved.  Moreover  it 
does  not  accompany  cases  oc- 
curring in  children. 

The  contagion  of  alopecia 
areata  appears  to  be  absolutely 
nil  and  at  any  rate  for  practical 
purposes  can  be  assumed  to  be 
so.  All  the  epidemics  of  alope- 
cia areata  which  have  been  de- 
scribed by  dermatologists  were 
epidemics  of  diagnostic  errors; 
alopecic  impetigo  or  ringworm 
Alopecia  areata  occurring  in 
rigr.  105.    Total    alopecia   decaivans  families  docs  uot  indicate  conta- 

(Sabouraud's   patient.     Photo,    by    Noire.) 

gion    any    more    than    peoriasis. 

The  general  treatment  should  be  directed  to  all  abnormalities  in 
the  health  of  the  patient.  Superalimentation  may  be  prescribed  for 
those  who  are  wasted,  and  a  restricted  diet  for  the  obese,  etc. 

Local  treatment  is  useful  in  all  benign  and  in  many  severe  cases. 
Tonic  and  stimulating  lotions  may  be  rubbed  daily  into  the  scalp : — 

Alcohol  90  per  cent 225  grammes  5j 

Soirit  of  lavender 25  "  3i 

Distilled  water 50  "  5ii 

Nitrate  of  potash 50  centigrammes  gr.  i 

Glacial  acetic  acid 4  grammes  gr.  4 

Local  irritant  applications,  such  as  ointments  containing  sulphur, 
resorcine  and  salicylic  acid,  are  useful;  also  daily  friction  with  the 
following : — 

(1)  Lactic    acid 10  grammes  3i  fs 

Alcohol  60  per  cent 50  "  Jj 

(2)  Glacial   acetic   acid i  gramme  gr.  12 

Hoffmann's  solution    .......  40  grammes  5J 

(3)  Tincture  of  iodine 5  grammes  m.  48 

Rectified    benzine 50  "  5j 

It  is  also  useful  to  alternate  the  lotions  from  time  to  time,  as  the 
scalp  appears  ^o  get  gradually  accustomed  to  them. 


224 


THE    SCALP    IN    THE    ADULT. 


In  severe  and  diffuse  cases,  or  in  cases  with  numerous  patches  of 
rapid  development,  tar  ointments  give  good  results.  They  are  more 
easy  to  apply  in  men  than  in  women  and  should  be  washed  off  on  the 
following  day. 

The  prognosis  depends  on  the  number  of  patches,  their  size  and 
rapidity  of  development,  the  thinning  or  oedema  of  the  skin,  the 
evolution  of  former  attacks,  the  cutaneous  reaction  to  medicament, 
etc.  It  should  always  be  guarded.  In  tuberculous  subjects  the 
prognosis  is  that  of  their  tuberculosis.  In  heredo-syphilis  it  is  always 
bad,  so  far  as  I  have  seen. 


PSEUDO    ALOPECIA    AREATA    OF    BROCQ. 


This  disease  has  nothing  in  common  with  alopecia  areata.     It  is 
a    follicular   cicatricial    atrophy   occurring   in    islands   disseminated 

over  the  scalp,  or  some  part 
thereof.  It  generally  oc- 
curs in  adults,  but  I  have 
seen  a  case  at  12  years.  It 
occurs  in  both  sexes.  The 
hair  falls  by  an  insensible 
process  of  dry  expulsive 
folliculitis,  analogous  to 
that  of  certain  non-tricho- 
phytic  sycosis  of  the  beard. 
The  affected  hairs  are 
easily  epilated  and  may  be 
already  atrophic,  friable. 
Or  normal.  It  does  not  re- 
grow  and  its  situation  is 
effaced. 

There  are  thus  formed 
smooth,  shining  surfaces, 
at  first  red,  but  afterwards 
white  and  slightly  con- 
cave. These  irregular  and 
amorphous  islands  extend 
and  coalesce  to  form  large 
smooth  surfaces,  on  which  may  be  seen  here  and  there  a  few  bunches 


Fig.  107.  Pseudo  alopecia  areata  of 
Brocq.  (Brocq's  tiatient.  Photo  by 
Sottas.) 


THE    SCALP    IN    THE    ADULT.  225 

of  two  or  three  healthy  or  diseased  hairs ;  the  remains  of  the  former 
boundaries  of  the  separate  islands. 

The  disease  extends  slowly  and  in  10  or  15  years  depilates  entire 
regions,  the  vertex  or  more  often  one  of  the  parietal  regions.  The 
disease  is  irregular  and  a-symmetrical ;  its  progress  is  sometimes 
remittent,  but  more  commonly  progressive.  No  regrowth  can  be 
expected  on  the  smooth  surfaces,  as  they  are  cicatricial. 

The  origin  of  this  disease  is  quite  unknown.  Treatment  consists 
only  in  applications  of  sulphur  in  different  forms,  which  retards  the 
evolution  of  the  disease,  but  does  not  guarantee  preservation  of  the 
actual  state.  Between  the  pseudo-alopecia  areata  of  Brocq  and 
Keratosis  pilaris,  dry  sycosis  and  especially  chronic  acne  decalvans, 
there  is  a  series  of  intermediate  clinical  forms. 


LUPUS    ERYTHEMATOSUS. 


The  scalp  is  one  of  the  seats  of  predilection  of  lupus  erythema- 
tosus, which  occurs  here  in  its  most  typical  form,  which  Dcvergie 

has  termed 
"  cretaceous 
herpes."  It 
consists  o  f 
several  ir- 
regular 
patches 
clearly 
marked  on 
the  scalp 
and  c  o  m- 
pletely  bald, 
each  having 
a  red  base 
and  a  bor- 
der of  adhe-. 

rent  chalky  squames.  These  patches  can  easily  be  felt  and  are  gen- 
erally slightly  concave ;  they  lead  to  cicatricial  atrophy  of  the  skin 
without  ulceration. 

The  patches  are  of  all  shapes  and  sizes ;  some  smaller  than  the 
end  of  the  finger  are  disseminated,  often  around  larger  patches ;  the 

15 


Tig.  108.     Lupus  erythematosus  of  the  scalp. 
(Fournier's  patient.      St.   Louis  Hosp.   Museum.      No.    1601.) 


226  THE   SCALP    IN    THE   ADULT. 

largest  are  generally  close  togetlier  on  the  vertex.  The  lesions  are 
always  discrete  and  there  may  be  a  single  large  patch  two  inches  by 
one  in  size ;  or  two  similar  ones,  with  two  or  three  smaller  distinct 
patches,  but  rarely  more.  The  lesions  are  chronic  and  slowly 
extensive  or  stationary.  They  may  disappear  spontaneously,  but 
this  is  rare. 

All  methods  oi  treatment  are  valueless  except  radiotherapy.  For 
the  cure  of  a  patch  of  lupus  erythematosus,  from  30  to  35  units  of 
Holtznccht  are  required ;  or  7  tints  B  of  our  radiometer  X,  which 
is  equivalent  to  7  sittings  with  a  fortnight's  interval.  Some  cases 
are  more  resisting  and  are  only  cured  after  a  radiodermatitis  of  two 
months,  represented  by  a  double  tint  B  at  a  single  sitting.  These 
facts  are  still  being  studied  and  they  must  not  be  taken  as  a  general 
rule.  Plasters  of  salicylic  and  pyrogallic  acid  ( 10  per  cent)  retained 
in  place  till  a  scar  is  formed  sometimes  give  results,  and  may  be 
used  if  radiotherapy  cannot  be  obtained. 

LICHEN    PLANUS    CORNEUS    ATROPHICUS. 

These  rare  lesions  may  occur  in  all  parts  of  the  body.  They  con- 
sist of  small,  irregular,  brown  papules,  very  similar  in  aspect  to 
warty  naevi.  They  begin  insidiously,  without  functional  symptoms ; 
attain  a  maximum  with  lesions  covered  with  adherent  squames,  and 
terminate  by  brown  cicatrices.  These  lesions  may  be  seen  in  patients 
affected  with  other  dermatological  lesions,  such  as  alopecia  areata 
and  psoriasis.  The  duration  of  the  lesions  is  from  3  to  10  years  or 
more.  They  come  and  go  irregularly.  They  are  always  very  dis- 
crete, and  from  5  to  10  may  be  found  in  evolution,  one  or  two  on  the 
legs,  arms  or  scalp.  Their  tuberculous  or  toxi-tuberculous  nature 
seems  to  me  to  be  probable,  although  I  have  not  demonstrated  it. 
The  treatment  which  I  propose  in  the  future  is  the  same  as  for  lupus 
erythematosus  (X-rays).  The  lesions  are  so  rare  and  of  such  slow 
evolution  that  the  patients  may  be  often  unaware  of  them.  They 
must  not  be  confounded  with  the  hyperkeratotic  form  of  lichen 
planus  of  Erasmus  Wilson  (p.  553). 

POST-INFECTIOUS   ALOPECIA. 

Every  infection,  even  apyretic  and  chronic,  such  as  muco-mem- 
branous  enteritis,  when  it  is  severe,  may  react  on  the  hair.    I  cannot 


THE    SCALP    IN    THE    ADULT. 


?.2^ 


review  all  the  diseases,  which  may  cause  alopecia.   Tuberculous  cach- 
exia in  the  child  is  accompanied  by  the  formation  of  a  thick  down 

on  the  whole  body ;  at  the 
same  time  a  number  of  hairs 
fall  and  are  replaced  by 
alopecic  ones,  an  inch  or 
more  in  length.  On  the  whole 
these  heads  of  hair  are  scanty 
and  expose  the  skin. 

These  cachectic  conditions 
occur  in  typhoid  and  the  erup- 
tive fevers,  but  the  effect  on 
the  scalp  is  more  marked  in 
adults  than  in  children. 

It  is  especially  after  the 
15th  year  that  fevers  are  fol- 
lowed by  marked  alopecia. 
This  may  occur  after 
measles,  small-pox,  scarla- 
tina, mumps,  erysipelas,  diph- 
theria, influenza  and  the  chief 
visceral  infections ;  pneu- 
monia, peritonitis  and  appendicitis.  Typhoid  fever  is  the  most 
depilating  of  the  infectious  fevers.  A  more  or  less  marked  alopecia 
may  occur  after  parturition,  even  when  normal,  or  after  puerperal 
infection.  A  slight  alopecia  may  follow  those  conditions  which  are 
accompanied  by  intense  local  inflammation,  such  as  erysipelas,  and 
all  these  have  a  fixed  date  for  their  alopecia.  That  of  erysipelas 
occurs  after  85  days'  interval.  Cases  vary  one  from  another  by  5 
days,  more  or  less. 

These  alopecias  generally  persist  for  6  weeks  with  a  maximum 
at  the  second  or  third  week.  The  rate  of  the  loss  of  hair  is  variable 
and  appears  to  depend  on  the  intensity,  duration  and  nature  of  the 
infection.  Several  differences  may  be  noticed  between  these  different 
alopecias,  if  they  are  often  observed.  That  of  typhoid  is  most  com- 
plete and  most  diffuse ;  that  of  syphilis  is  parietal  and  in  patches. 

The  mechanism  of  these  alopecias  appears  to  consist  in  atrophy  of 
the  papilla  and  cessation  of  its  function,  under  the  influence  of  tox- 
ins in  the  circulation.  The  long  interval  between  the  infection  and 
the  alopecia  depends  on  the  slowness  of  the  circulation  and  elimina- 


Fig.  109.     Post-eryslpelatous   Alopecia. 
(Brocq's   patient.      Photo,    by   Sottas.) 


228  THE    SCALP    IN    THE    ADULT. 

tion  of  the  toxins,  and  also  on  the  fact  that  the  dead  hair  is  detached 
at  its  base  and  rises  slowly  in  the  follicle,  but  does  not  fall  at  once. 
The  treatment  of  these  forms  of  alopecia  is  always  successful 
because  nature  is  sufficient  to  repair  them  partially.  The  fall  is 
always  followed  by  regrowth,  but  this  is  often  incomplete  when  left 
to  itself.  Moreover,  an  infectious  alopecia  often  leads  to  a  pityroid 
alopecia,  which  prolongs  it  indefinitely.  All  the  lotions  which  we 
have  recommended  for  pityriasis  may  be  used  in  infectious  alopecias. 
At  the  St.  Louis  Hospital  the  following  stimulating  lotion  is  often 
prescribed : — 

Camphorated  alcohol 125  grammes     5j 

Essence  of  turpentine 25  "  3i  s.s. 

Liquid    ammonia 5  "  m.  20 

This  has  the  disadvantage  of  soiling  the  hair,  and  on  this  account 
the  following  lotions  are  preferable : — 

(i)   Hoffmann's    Solution  250  grammes  5J 

Liquid    ammonia  4  "  m.  8 

Distilled   water    .    .  25  "  m.  .48 

Hydrochlorate  of  pilocarpine    50  centigrammes  gr.  i 

Spirit  of  lavender  .  25  grammes  m.  48 

(2)  Anhydrous    Acetone  1  ». 

^  ^  -^  '   aa     125  grammes  3j 


J 


Alcohol:  96  per  cen 

Spirit  of   rosemary    1^^       ^^  .  5j  ^  ^ 

Tincture  of  jaborandi  J 

Glacial  acetic  acid  .  4  "  gf.  8 

Formol i  gramme  gr.  2 

It  is  advantageous  to  vary  the  formulae  employed  every  3  or  6 
weeks,  to  prevent  the  scalp  becoming  accustoined  to  any  particular 
one.  After  an  infectious  disease  the  treatment  of  the  alopecia  and 
the  regrowth  take  6  or  7  months. 


SYPHILIS    OF   THE   SCALP. 

Syphilitic  lesions  of  the  scalp  include  (i)  Syphilitic  alopecia,  (2) 
Secundo-tertiary  Syphilides,  (3)  Gummata. 

I.  Syphilitic  Alopecia.     This  occurs  between  the  5th    and    8th 


THE   SCALP    IN    THE   ADULT. 


229 


months. 


It  may  follow  the  general  syphilitic  infection  after  an  inter- 
val of  3  months, 
and  many  charac- 
ters connect  it 
with  other  infec- 
t  i  o  u  s  alopecias 
and  it  often  ap- 
pears 2  or  3 
months  after  the 
roseola.  But  all 
these  dates  are 
variable.  How- 
ever, syphilitic  al- 
opecia does  not 
occur  after  the 
first  year  of  the 
disease. 

This  form  of 
alopecia  is  so  pe- 
culiar that  it  has 
often  been  suffi- 
cient to  diagnose 
an  unrecognised  syphilis.  It  is  temporo-parietal,  irregularly  diffuse ; 
and,  when  the  hair  is  worn  short,  has  the  appearance  of  having 
been  badly  cut.  At  each  of  these  places  a  tuft  of  a  dozen  hairs  has 
disappeared,  leaving  a  ''clearing" ;  these  spaces  are  even  visible  in 
women  with  long  hair.  The  eyebrows  are  marked  with  parallel 
"hatching" ;  the  cervical  glands  are  enlarged  and  mucous  patches 
may  be  found  in  the  mouth.  The  remains  of  a  hard  chancre,  ingui- 
nal glands  and  sometimes  roseola  may  be  visible. 

Syphilitic  alopecia  affects  all  the  hair  of  the  body,  but  is  nowhere 
so  pronounced  as  on  the  scalp  and  eyebrows  (p.  140).  It  lasts  from 
6  to  8  weeks  and  is  always  followed  by  spontaneous  regrowth ;  but 
in  young  men  it  is  often  continued  by  a  seborrhoeic  alopecia  of  the 
vertex,  to  which  it  predisposes. 

The  local  treatment  of  syphilitic  alopecia  is  the  same  as  for  infec- 
tious alopecias ;  the  general  treatment  is  that  of  secondary  syphilis. 
Even  if  the  syphilis  is  not  treated  the  alopecia  is  followed  by 
regrowth,  which  may  give  patients  a  false  security.  This  proves 
nothing  as  to  the  further  progress  of  the  syphilis  which  causes  it. 


Fig.  110.     Syphilitic     alopecia,     rather     more     marked 
than   usual.      (Sabouraud's   patient.      Photo,    by   Noir6.) 


236  THE    SCALP    IN    THE   ADULT. 

2.  Secondary  Syphilides  of  the  Scalp.  These  are  of  several 
kinds ;  roseolous  spots  and  secondary  papules,  and  are  only  epiphe- 
nomena  in  the  course  of  secondary  syphiHs.  In  one  case,  however, 
I  have  seen  papules  become  centres  of  an  alopecic  area.  The  most 
interesting  are  the  papulo-corymbose  or  papulo-ulcerative  lesions  of 
malignant  secondary  syphilis  (also  an  epiphenomenon  in  the  course 
of  severe  secondary  syphilis),  and  the  secundo-tertiary  syphilides 
which  may  be  seen  to  develop  singly  on  the  scalp,  or  in  association 
with  analogous  lesions  of  the  neck,  face  and  beard. 

They  may  appear  some  years  after  the  beginning  of  the  disease ; 
sometimes  lo  or  12  years.  They  are  characterised  by  their  distribu- 
tion in  rings  of  6  or  8  papules,  or  in  a  semicircle,  or  horseshoe,  but 
always  following  some  design.  The  circle  occurs  everywhere,  but 
requires  to  be  looked  for;  the  papules  are  disseminated  on  it  and 
each  is  red  and  dry  or  scaly  and  psoriasiform,  or  ulceiative  and 
crusted.  It  is  the  topography  of  the  lesions  which  makes  the  differ- 
ential diagnosis.  This  is  confirmed  by  attentive  examination  of  each 
papule  which  shows  the  difference  from  psoriasis,  acne,  acne  necro- 
tica,  etc.    The  history  of  former  syphilis  may  be  obtained. 

Local  treatment  by  ointments  : — 

Red  oxide  of  lead 1  ^, 

„.        ,  U      aa     I  gramme       gr.  10 

Cinnabar  J 

Vaseline 30  grammes     3J 

or  plasters  such  as  emplastrum  de  Vigo,  have  little  effect.  The  best 
results  are  obtained  by  the  daily  injections  of  biniodide  of  mercury 
(2  centigrammes)  ;  or  weekly  injections  of  grey  oil  (7  centi- 
grammes). This  treatment  should  be  continued  for  a  long  time, 
for  the  infection  is  of  old  standing  and  persistent. 

3.  Gummata  and  Syphilitic  Sequestra.  Tertiary  syphilis  may 
attack  the  scalp  in  the  form  of  gummata  and  bony  sequestra.  These 
cases  are  rare,  but  not  exceptional.  The  gumma  has  the  appearance 
of  an  abscess,  but  the  functional  signs  of  local  heat  and  pain  are 
wanting. 

The  open  gumma  has  the  same  characters  as  elsewhere ;  the  circu- 
lar or  crescentic  form  of  the  ulceration,  the  greenish  yellow  core,  the 
progressive  trench  between  this  and  the  walls  of  the  ulcer  and  the 
deep  crater  left  after  removal  of  the  core,  are  all  characteristic. 

The  sequestrum  commences  more  often  on  the  surface  than  deeply, 
in  the  form  of  a  malignant  ulcerating  syphilide,  rather  than  by  a 


THE    SCALP    IN    THE   ADULT.  231 

gumma.  Both  origins  are  possible.  When  the  ulceration  lays  bare 
the  sequestrum,  the  ulcerating  sinuous  appearance  of  the  sore,  and 
the  offensive  odour  of  the  suppurating  bone  render  the  lesion  hor- 
rible. At  the  beginning  the  formation  of  the  sequestrum  may  be 
painful,  but  it  is  more  often  painless.  The  elimination  of  the  seques- 
trum is  easy,  if  the  sore  is  opened  sufficiently  to  allow  extraction. 
However,  incarceration  of  the  sequestrum  may  necessitate  surgical 
measures.  These  lesions,  which  are  interminable  when  their  nature 
is  misunderstood,  are  cured  in  a  few  weeks  by  a  proper  mixed 
treatment  (p.  650). 

In  the  absence  of  treatment  by  injections  many  cases  may  be 
cured  by  the  older  methods,  such  as  Syrup  of  Gibert  or  Van  Szvie- 
ten's  liquor,  with  iodide  of  potassium  15  to  60  grains  daily. 

Local  treatment  is  of  little  value. 


THE  SCALP  AT  MATURE  AGE. 


P-232 


Alcoholic  pruritus  p.  234 


Acne  necrotica    .   p.  235 


-Chloric  Acne 


p.  236 


At  mature  age  dry,  squamous,  pityroid  eczemas 
frequently  occur,  and  the  red  eczemas  called  "ar-  L  j)ry  Eczema 
thritic;" I 

.    .    .  Also   many  artificial  traumatic  rf^rma/j7^*,T  Traumatic  derma- 
ainong  which  some  arise  from  noxious  dyes  .    .    .]      titis P- 233 

It  is  also  at  mature  age,  and  more  often  in 
women,  that  pruritus  of  the  scalp  occurs,  without 
objective    lesions 

The  scalp,  like  the  face,  is  one  of  the  scats  of 
election  of  acne  rodens,  and  necrotic  and  varioli- 
form  acne 

.  .  .And  the  acne  polymorphe  of  abnormal 
development,  which  is  observed  in  zvorkcrs  in 
chlorine 

After  having  discussed  these  different  morbid 
types,  wc  shall  consider  the  ultimate  evolution  of 
common   baldness  and  the   complications  which   it 

may   present 

Among  these  complications  zve  shall  study  cir- 
cinate,  poly-micro-cyclic  pityriasis  which  almost 
only  develops  on  the  scalp  of  the  bald 

...  And  sclerous  atrophy  of  the  follicles,  end-']  Alopecia  by  follicu- 
ing  m  their  disappearance  by  cicatrisation,  either  on  r    1       sclerosis  d  2^8 

scalps  already  bald,  or  on  the  scalp  in  women   .    .    .J 

And  we  shall  study,  especially  in  zvomen,  the  alo- 1  Alopecia  tonsurans 
pecia  tonsurans  zi'hich  is  often  seen  after  45  years  I      of  women     .    .   p.  239 

There  exists  in  the  adult  and  even  at  mature  age  " 
in  rare  cases,  a  chronic  folliculitis,  in  patches,  an- 
alogous to  the  impetigo  of  Bockhart  of  children  .    . 

This  process,  like  many  others,  ends  in  a  cicatrix,^ 
We  shall  next  review  the  chief  causes  of  the  r/Va- I  Cicatrices      .    .    .   p.  240 
trices  zvhich  may  be  met  with  on  the  scalp   ... 


Evolution  of  bald- 
ness      p.  236 


Pityriasis  circinata 
of  the  bald   .    .   p.  237 


Chronic 
litis 


follicu- 


P-239 


Lastly,  we  shall  devote  a  few  words  to  dermato- 
logical  processes,  of  little  importance  in  this  situ- 
ation, but  zvhich  it  is  necessary  to  know,  and  to  treat 


IVIolluscum  con- 
t  a  g  i  o  s  u  m  . 
Warts.  Sebace- 
ous cysts.  Epi- 
thelioma   ...   p.  241 


DRY    ECZEMA. 

The  more  an  individual  advances  in  age.  the  more  the  eczemas 

which  he  may  present  become  dry,  red  and  squamous  and  the  less 

they  become  moist  and  impetiginous.^ 

^  It  must  be  understood  that  all  forms  of  eczema  may  occur  at  any  age, 
but  I  deal  here,  as  everywhere  in  this  volume,  with  generalities. 


THE    SCALP   AT    AlATURE   AGE. 


233 


A  man,  especially  when  obese,  having  preserved  all  his  hair,  or  at 
least  half  of  it,  often  presents  dry  eczema  on  the  regions  remaining 
hairy.  This  eczema  is  characterised  by  excessive  itching,  which 
comes  on  several  times  a  day,  especially  at  night.  This  itching  causes 
the  falling  of  the  pellicles.  After  each  attack  the  scalp  is  moist  to 
the  touch.  On  close  examination  a  slight  exudation  is  seen  produced 
from  punctiform  orifices,  which  dries  between  the  squames  without 
forming  crusts.  The  skin,  which  is  warmer  than  usual,  is  thickened 
by  a  hard  oedema,  which  does  not  pit  on  pressure. 

In  severe  cases  this  eczema,  although  more  marked  in  hairy 
regions,  oversteps  the  limits  of  the  scalp  and  extends  onto  the  neck, 
face  and  eyelids,  causing  similar  lesions.  It  may  occur  in  forms 
which  are  more  exudative  or  more  squamous,  and  others  character- 
ised by  more  pronounced  infiltration  of  the  skin. 

Like  all  other  forms  of  eczema  this  has  no  determined  etiological 
cause.  It  has  been  attributed  to  the  arthritic  diathesis,  but  this  term 
is  vague  and  of  impossible  definition.  Careful  examination  of  the 
general  condition  will  often  furnish  indications  for  treatment.  Alka- 
lies are  prescribed  for  those  with  excess  of  urates,  and  aperient 
waters  to  those  with  oxaluria  or  skatol  or  indican  in  the  urine.  The 
gastric  and  intestinal  digestion  are  regulated  by  appropriate  means ; 
carbonate  of  lime,  magnesia,  saline  laxatives,  drastic  purgatives,  etc. 

The  local  treatment  comprises  the  use  of  pastes  containing  tar: — 

Oil  of  Cade    .    .    .    .     \    ^^  5  grammes     3j  s.s. 

Oxide  of  zinc    .    .    .     j 

Ichthyol    1 

Resorcine k    aa     i  to     5  grammes     gr.  16-80 

Oil  of  birch    ....    J 

Vaseline 30  grammes     3j 

The  active  agents,  the  tars  and  resorcine,  may  be  diminished  or 
increased  according  to  the  tolerance  of  the  patient.  Also,  according 
to  the  case,  the  ointments  are  removed  by  very  mild  soaps,  or  by 
sweet  oil  of  almonds. 

ARTIFICIAL   DERMATITIS. 

Artificial  dermatitis,  on  the  scalp  as  elsewhere,  may  arise  from 
many  causes.  The  most  common  causes  are  lotions  of  turpentine, 
salol,  naphthol,  tincture  of  cantharides,  capsicum,  etc.,  or  applica- 
tions of  sulphur  or  alkaline  sulphides  in  the  form  of  powder,  oint- 


234  THE    SCALP   AT    MATURE   AGE. 

ment  or  lotion.  The  scalp  reddens  very  little  and  the  redness  is 
difficult  to  see;  but  the  patient  complains  of  a  sensation  of  heat, 
smarting  or  itching,  and  the  skin  is  sensitive  and  appears  shrunken. 
There  is  always  pain  in  the  sub-occipital  glands.  These  forms  of 
dermatitis  may  be  dry  and  desquamating,  but  this  is  rare.  They  are 
usually  red  and  moist,  and  situated  on  the  whole  scalp  or  part  of  it. 
Dyes,  especially  those  fixed  with  an  alkaline  sulphide,  or  those  which 
contain  paraphenylene-diamine,  act  exactly  in  the  same  way  as  trau- 
matic medicaments.  Their  effects  are  identical  and  the  cutaneous 
reaction  is  the  same  with  each  traumatic  agent. 

In  these  cases  of  dermatitis,  caused  by  dyes,  powders,  pastes  and 
ointments,  the  irritation  has  a  remarkable  tendency  to  extend  beyond 
the  limits  of  the  scalp,  onto  the  face,  temples,  retro-auricular  regions, 
antero-lateral  parts  of  the  neck,  and  even  the  trunk.  These  reactions 
depend  not  only  on  the  traumatic  agent  and  its  dose,  but  especially 
on  the  skin  to  which  it  is  applied.  One  skin  may  be  irritated  by  the 
mildest  application  while  another  does  not  react  to  the  most  irri- 
tating. There  exist  irritable,  or  cczematisable  skins.  Skins  which 
present  these  artificial  forms  of  dermatitis  have  often  had  "sponta- 
neous" eczema,  or  will  have  it  in  the  future. 

PRURITUS   WITHOUT   LESIONS. 

Pruritus  without  lesions  occurs  in  all  situations,  and  from  very  dif- 
ferent causes.  It  is  the  same  on  the  scalp.  But,  as  a  rule,  pruritus 
of  the  scalp  occurs  in  women  of  middle  age,  and  is  due  to  alcoholism. 

On  examination  the  scalp  is  found  to  be  clean,  not  pellicular  and 
without  any  lesion.  However,  the  patient,  who  often  has  a  strange 
fixity  of  regard  and  a  rather  haggard  expression,  complains  of  pruri- 
tus which  wakes  her  from  sleep,  and  an  intolerable  itching  "like  ani- 
mals running  about  and  pricking,"  etc. 

The  patient  has  nightmares,  dreams  of  animals,  fires,  drowning, 
falling  down  a  hole,  etc.  In  the  morning  she  coughs,  spits  and  has 
nausea;  the  hands  tremble,  etc.  Alcoholism  in  these  cases  is 
obvious. 

Locally  a  volatile  lotion  containing  menthol  (^  to  i  per  cent) 
may  be  prescribed.  More  important  is  the  following  regime :  On 
awakening  a  large  draught  of  decoction  of  chicory  or  of  ground  ivy 
is  taken.  This  is  the  method  of  dilution.  With  the  same  view  pre- 
scribe \'ichy  water,  with  a  diet  in  which  is  insisted  the  total  absten- 


THE    SCALP   AT    MATURE   AGE.  23$ 

tion  from  alcohol  and  all  fermented  drinks.  For  certain  nervous 
subjects  alcohol  is  a  poison,  and  after  three  months  of  this  regime 
the  symptoms  will  have  disappeared. 

The  treatment  includes  the  removal  of  the  irritant  substances. 
Cleansing  with  fresh  oil  of  almonds  is  usually  sufificient ;  after  which 
mild  ointments,  or  if  these  cannot  be  borne,  fresh  lard  relieves  the 
iritation  in  a  few  days. 


ACNE  NECROTICA. 

In  its  average  form  acne  necrotica  is  a  disease  which  only  attacks 
the  temporo-frontal  boundaries  of  the  scalp  in  men  between  45  and 
50.  In  its  more  severe  forms  it  has  no  limits  and  may  cover  the 
scalp  from  the  age  of  30.  It  is  a  paroxysmal  disease  which  recurs 
several  times  a  year  in  a  more  or  less  intense  degree.  Each  crop 
contains  from  10  to  200  lesions.  Each  lesion  consists  of  a  flat, 
umbilicated,  circumpilary  pustule  which  develops  without  opening 
and  forms  a  discoid  scab,  which  falls  after  some  time  with  the 
central  hair,  leaving  a  varioliform  cicatrix.  It  resembles  an  impetigo 
of  Bock  hart  with  necrosing  elements.  Each  outbreak  is  accompanied 
by  painful  sub-occipital  adentitis.  In  its  nature,  structure  and 
cause  the  pustule  of  acne  necrotica  is,  anatomically  and  bacteriolog- 
ically,  closely  allied  to  that  of  impetigo  of  Bockhart  (impetigo  rodens 
of  Hillairet-Gaucher) .  Both  are  caused  by  the  staphylococcus 
aureus,  but  in  acne  necrotica  the  staphlococcic  infection  is  grafted 
on  a  primary  bacillary  seborrhoeic  infection. 

Acne  necrotica  may  be  excessively  recurrent  and  each  recurrence 
may  be  very  intense.  It  is  then  one  of  the  most  incurable  of  the  der- 
matoses. Perhaps  the  general  health  of  the  patient  accounts  partly 
for  the  incessant  recurrence,  in  the  way  that  glycosuria  renders  a 
furunculosis  chronic.  But  we  are  ignorant  of  this  hypothetical  con- 
dition and  its  treatment. 

Local  treatment  is  that  of  acne  and  of  impetigo  of  Bockhart,  by 
means  of  sulphur  and  mercury  ointments.  These  are  successful 
against  the  eruption,  but  do  not  prevent  recurrence.  Patients  who 
are  cured  without  recurrence  owe  this  to  the  benignity  of  the  disease 
and  the  power  of  their  leucocytic  defence,  rather  than  to  the  treat- 
ment. 


r  I   gramme  gr.  i6 

} 


y  aa     I  gramme  gr.  i6 


236  THE    SCALP   AT    MATURE   AGE 

(i)  Precipitated  Sulphur 

Resorcine 

Vaseline 

Lanoline /    ^^     '''  ^'■^"^"^^s  5j 

(2)  Precipitated  Sulphur  ...  id  grammes  5j 
Alcohol  60  per  cent.  ...  20  "  3ii 
Rose  Water 70          "  SJ 

(3)  Precipitated  E^ulpliur  . 

Cinnabar  

Vaseline 30  grammes  oi 

(4)  Oil  of  Cade 10  grammes  5iv 

Precipitated  Sulphur  ...  i  gramme  gr.  24 

Resorcine l         "  gr-  24 

Lanoline 20  grammes  -,} 

CHLORIC    ACNE. 

Chloric  Acne  has  been  mentioned  with  acne  of  the  face  (p.  16). 
It  is  the  polymorphous  acne  of  workers  in  the  preparation  of  chlo- 
rine. On  a  generalised  seborrhoea  develop  all  forms  of  polymor- 
phous acne,  chiefly  the  comedo  and  cystic  acne.  This  seborrhoea 
affects  not  only  the  vertex  of  the  scalp,  but  also  the  temporal  and 
retro-auricular  regions  and  the  back  of  the  neck.  An  interesting 
point  in  this  excessive  seborrhoea  is  that,  whenever  the  microbacil- 
lary  seborrhoeic  cylinders  occur  on  the  scalp,  the  hair  falls.  There 
results  a  diffuse  alopecia  of  all  regions  of  the  scalp,  and  in  large 
areas.  It  is  a  demonstration  of  the  seborrhoeic  microbacillary  origin 
of  common  baldness. 

Treatment  consists  in  suppression  of  the  cause.  Sulphur  baths, 
sulphur  lotions  and  soaps,  sulphur  pastes  and  ointments  are  used  in 
this  form  of  acne  with  the  same  results  as  in  ordinary  polymorphous 
acne  (p.  15). 

ULTIMATE    EVOLUTION    OF    BALDNESS. 

The  ultimate  evolution  of  baldness  depends  entirely  on  the  age 
when  it  commenced.  When  it  was  complete  on  the  vertex  at  the 
age  of  30  years,  at  70  the  scalp  is  reduced  to  a  circumferential  band 
of  fine  wooly  hairs,  often  scarcely  visible.  Baldness  of  the  vertex 
is  thus  much  increased  and  is  augmented  by  a  complimentary  alo- 
pecia extending  from  the  borders  of  the  scalp  towards  the  centre 
which  has  extended  beyond  the  former  limits  of  the  scalp  by  two 
fingers'  breadth. 


THE    SCALP    AT    MATURE    AGE.  237 

In  baldness  of  the  vertex,  which  is  incomplete  at  30  but  complete 
at  50,  the  hair  round  the  head  may  be  preserved.  Generally  it  is 
scanty  on  the  temples  and  around  the  ears. 

Incomplete  baldness  may  be  complicated  with  recurrent  pityriasis, 
which  is  very  often  a  dry  eczema  and  not  a  true  pityriasis;  and 
with  all  the  eruptions  which  occur  on  the  seborrhoeic  substratum 
(circinate  pityriasis  and  acne  necrotica). 

Lastly,  diffuse  sclerous  atrophy  and  the  disappearance  of  a  large 
number  of  follicles  may  occur,  which  is  not  a  result  of  normal  sebor- 
rhoeic evolution,  but  a  complication  of  seborrhoea. 

Many  of  these  complications  have  their  own  special  treatment, 
but  that  of  the  baldness  itself,  at  these  periods,  is  the  same  as  for 
those  of  which  we  have  spoken  above  (p.  212). 

Sulphur  or  tar  soap  may  be  used  every  night  and  the  following 
lotion  in  the  morning: — 

Alcohol,  96  per  cent 250  grammes  3j 

Coaltar,  saponified 25           "  5j 

Tincture  of  quillaya 25           "  3j 

Liquid  Ammonia 5           "  m.  12 

In  cases  where  the  seborrhoeic  flux  is  considerable,  daily  friction 
with  sulphide  of  carbon  saturated  with  sulphur  causes  the  excess 
to  disappear,  and  is  one  of  the  best  and  most  simple  applications,  in 
spite  of  its  odour  and  inflammability.  It  must  not,  however,  be 
applied  to  eczematous  subjects. 

PITYRIASIS    CIRCINATA    OF   THE    BALD. 

On  the  bald  vertex  may  arise  a  pityriasis  with  ornamental,  geo- 
graphical, poly-micro-cyclic  figures,  composed  of  segments  of  small 
circles,  each  with  a  red  border  a  millimetre  in  width  and  covered 
with  small,  yellow  fatty  scales.  This  is  one  of  the  most  common 
types  of  steatoid  superseborrhoeic  pityriasis  (spore  of  Malasses: 
cocci  with  grey  culture)  ;  one  of  the  types  of  the  seborrhoeic  eczema 
of  Unna,  and  of  the  "Seborrhoeids"  of  French  authors.  It  is 
remarkable  that  these  forms  of  pityriasis  only  occur  on  the  scalp  of 
bald  subjects. 

They  may  be  quickly  cured  by  sulphur  or  tar  ointments,  applied 
at  night  and  washed  off  in  the  morning. 


238  THE    SCALP    AT    MATURE    AGE. 

(i)   Precipitated  Sulphur  ...  "1 

Ichthyol r  aa       i  gramme  gr.  48 

Resorcine ■' 

Oil  of  cade 

Lanoline [.  aa     10  grammes  5] 

Vaseline 


(2)   Precipitated  sulphur   ...  3  grammes  gr.  48 

Vaseline \  „ 

Ceratum Jaa     15  5J 

When  the  pityriasis  has  disappeared  the  use  of  tar  or  sulphur 
soap  should  be  continued  to  keep  the  seborrhoeic  skin  in  condition 
and  avoid  recurrent  eruptions,  such  as  acne  necrotica,  which  devel- 
ops on  the  same  soil. 

ALOPECIA    BY    FOLLICULAR   SCLEROSIS. 

Very  often,  but  not  always,  a  total  follicular  atrophy  develops 
on  the  denuded  scalp,  resembling  that  caused  by  the  pseudo  alopecia 
areata  of  Brocq  (p.  224).  Among  the  empty  hair  follicles,  or  those 
occupied  by  downy  hair,  some  present  a  circular  elevation  and  some- 
times a  slight  border  at  their  orifices.  This  appears  to  be  a  sign  of 
infection  of  the  follicle  by  the  accessory  cocci  of  seborrhoea  and 
pityriasis,  at  any  rate  the  downy  hairs  removed  from  the  follicles 
are  infected  with  these  cocci  down  to  their  roots.  This  process  ends 
in  fibrous  transformation  and  disappearance  of  the  follicle  up  to  its 
orifice.  The  interval  between  the  sclerosed  follicles  become  smooth 
and  cicatricial. 

This  process  may  also  be  seen  in  women  of  middle  age  who  have 
hitherto  preserved  their  hair,  and  appears  to  be  progressive  and 
incurable.  In  bald  men  this  is  not  of  much  importance,  as  it  does 
not  extend  beyond  the  limit  of  the  baldness ;  but  in  women  it  leads 
to  permanent  diflfuse  alopecia. 

Treatment  by  sulphur  lotions  and  ointments  generally  diminishes 
the  extension  of  the  proceFs.  but  does  not  arrest  it  completely: — 


(l)  Precipitated  Sulphur 
Oxide  of  zinc  .... 
Talc 


equal  parts 


(2)   Precipitated    Sulphur 10  parts     5j 

Alcohol,  90  per  cent 10       "         3j 

Distilled  water 80      "        I] 


THE    SCALP    AT    MATURE    AGE.  239 

ALOPECIA   TONSURANS   IN   WOMEN. 

Women,  towards  the  age  of  45  or  50,  often  present  a  slowly  pro- 
gressive alopecic  patch  on  the  vertex  of  the  head.  This  is  often 
attributed  to  wearing  a  chignon,  or  to  the  mode  of  coiflfure,  combs, 
hairpins,  etc. ;  in  fact,  to  ill-defined  causes. 

It  may  occur  without  pityriasis  or  local  seborrhoea,  by  a  slow  pro- 
cess of  sclerosis  analogous  to  that  studied  in  the  preceding  para- 
graph. 

It  forms  an  oval  patch  of  almost  complete  alopecia,  on  which  the 
surface  of  the  skin  is  smooth,  cicatricial  and  often  bordered  by  friz- 
zled hairs,  which  appear  to  emerge  from  their  orifices  as  if  from 
curling  tongs. 

Sometimes  the  follicular  process  is  more  marked  and  the  follicular 
orifices  are  surrounded  by  a  circular  horny  elevation,  or  a  red,  hardly 
perceptible  margin.  This  alopecia  is  permanent  and  as  a  rule  not 
amenable  to  treatment.  Sometimes,  when  follicular  reaction  is  indi- 
cated by  a  circumpilary  red  border,  sulphur  applications  may  be  pre- 
scribed. But  I  have  never  seen  treatment  arrest  the  slow  extension 
of  the  process, 

CHRONIC   FOLLICULITIS   OF  THE   SCALP. 

One  sometimes  sees,  although  rarely,  a  chronic  follicular  process 
establish  itself  and  increase  slowly  on  the  scalp  of  the  adult,  and 
even  at  mature  age  or  old  age.  It  has  the  characters  of  chronic 
pustular  dermatitis  (impetigo  of  Bockhart)  which  we  have  studied 
in  the  child  (p.  183),  with  all  its  objective  symptoms,  including  sub- 
occipital adenitis.  The  functional  symptoms,  local  heat,  smarting 
and  pruritus,  appear  to  be  more  marked ;  the  pustules  being  miliary 
and  cause  hardly  any  projection  on  the  skin. 

This  process,  the  particular  chronicity  of  which  is  not  explained, 
persists  for  years  and  ends  in  the  formation  of  an  irregular  cicatrix, 
with  a  margin  at  first  red,  then  white,  in  the  centre  of  lesions  which 
extend  peripherally. 

In  these  cases,  besides  sulphur  applications,  depilation  by  the 
X-rays  should  be  tried,  which  gives  such  excellent  results  in  chronic 
follicular  affections  (p.  196). 

(I)   Precipitated  Sulphur |  ,^, 

Uxide  of  zinc J 


240  THE    SCALP    AT    MATURE    AGE. 

(2)  Precipitated    Sulphur    .    .    .    .~| 

Glycerine |     aa     10  grammes     gr.  48 

Alcohol,  90  per  cent  ....  20  "  5ii 

Rose  water 60  "  3} 

(3)  Precipitated    Sulpnur    ....  3  grammes  gr.  45 

Oxide  of  zinc 6          "'  5i  s.s. 

Lanoline 30          "  5j 

Distilled  water  q.  s. 

CICATRICES. 

The  scalp  is  liable  to  all  forms  of  cicatrices,  which  when  once 
formed  persist  indefinitely.  The  scalp  of  old  people  may  thus  pre- 
sent many  cicatrices  of  different  origin. 

There  are  the  traumatic  cicatrices  which  are  linear,  or  angular; 
the  cicatrices  of  boils,  which  are  numerous  and  punctiform;  and 
cicatrices  of  acne  necrotica,  a  little  larger  and  varioliform. 

There  are  the  cicatrices  of  cold  abscesses  and  of  bony  suppura- 
tions, larger  than  the  preceding  and  deep  and  radiating;  the 
elongated  and  geographical  cicatrices  of  lupus  erythematosus;  the 
multiple  irregular  cicatrices  of  the  pseudo  alopecia  of  Brocq;  the 
cicatrices  of  favus,  irregular  in  form  with  one  patch  larger  than  the 
others.  The  latter  and  the  scars  of  burns,  which  resemble  them 
closely,  always  present  surviving  hairs  disseminated  on  the  surface. 

There  are  also  the  deep  cicatrices  of  vitriol,  and  the  still  more 
depressed  scars  of  tertiary  syphilitic  sequestra,  under  which  the 
bone  can  be  felt  to  have  more  or  less  disappeared. 

These  are  the  principal  causes  of  cicatrices  of  the  scalp,  but  there 
are  many  others,  and  it  is  impossible  to  enumerate  them  all.  Those 
mentioned  are  the  most  common. 

When  a  cicatrix  is  imperfect  the  deformity  may  be  corrected  by 
linear  scarifications  of  the  borders  and  projecting  seams.  By  this 
means  bridled  and  irregular  scars  may  be  made  regular  and  flat ; 
but  this  is  all  that  can  be  done.  Hodara  has  proposed  reimplantation 
of  hair,  taken  from  the  head  of  the  same  subject,  in  deep  scarifica- 
tions of  the  stirface  of  the  cicatrix.  The  results  which  I  obtained  in 
the  single  case  in  which  I  tried  this  difficult  and  painftil  method 
were  mediocre.  In  many  other  cases  I  have  tattooed  the  surface,  and 
the  results  appear  to  favour  the  practice  of  this  method  when  the 
cicatrix  cannot  be  concealed  by  false  hair  or  by  the  surrounding 
normal  hair, 


THE    SCALP    OF    MATURE    AGE.  241 

VARIA. 

The  scalp  may  present  many  dermatological  types,  less  important 
than  the  preceding,  concerning  which  a  few  words  may  be  said. 

Molluscum  contagiosum.  This  forms  a  discrete  or  abundant 
crop  of  soft,  round,  pink,  raised  and  crateriform  lesions,  the  cavity 
of  which  is  occupied  by  a  semi-horny  substance  which  may  be 
expressed  by  the  finger  nails.  This  lesion,  which  is  more  common 
on  the  face,  and  in  the  child,  may  occur  on  bald  scalps  and  attain 
considerable  dimensions.  The  treatment  is  the  same  everywhere,  by 
means  of  the  curette,  which  is  almost  painless  and  gives  good  results. 

Warts.  Villous  warts,  covered  with  small  horny  projections, 
are  somewhat  rare  on  the  scalp,  but  may  occur  in  children,  adults 
and  in  the  aged.  They  may  be  treated  by  applications  of  chromic 
acid  (30  per  cent),  or  salicylic  acid  (50  per  cent),  or  by  the  gal- 
vano-cautery. 

Sebaceous  cysts.  Sebaceous  cysts  may  occur  in  adults  or  in 
the  aged.  When  they  are  closed  they  should  be  removed  surgically ; 
the  application  of  caustics  is  contra-indicated.  When  the  cysts  are 
open  and  obstructed  by  a  fatty  core,  the  tumour  may  often  be  evacu- 
ated by  this  orifice  by  separating  the  cyst  with  a  blunt  probe  and 
expressing  the  contents  slowly. 

Epithelioma.  Epithelioma  is  rare  on  the  scalp  except  when 
supercicatricial.  It  has  the  same  ulcerative  or  proliferating  char- 
acters as  elsewhere.  As  in  all  cases  of  superficial  epithelioma,  radio- 
therapy should  be  tried  first  (p.  33). 


16 


THE    NECK. 

The  neck  presents  the  following  dermatological  lesions  most  fre- 
quently : — 

Those  caused  by  fleas,  bugs  and  mosquitoes  .    .    Parasitic  lesions     p.  242: 

The  coneestive  patches  which  emotional  persons^  -r.    ..  , 

.        ,1    .    .    J-           .1  LPudic  erythema  .   p  243 

often   present,   called   pudic   erythema J 

The  traumatic  lesions  called  dermographism   .    .    Dermographism     p.  243 

And  true  urticaria;   essential  or  ab  ingestis  .   .    Urticaria   ....   0.2.14 

1  Erythema      multi- 
The  "rosette"  lesions  of  erythema  multiforme  .  V     forme  o  244 

The  circular,  squamous  lesions  of  pityriasis  rosea   Pityriasis  rosea  .   p.  245 

Eczemas  secondary   to   eczemas  of  neighbouring} 
^     ,  r  Eczema      ....   p.  245 

parts J 

The  collar  of  grey  lesions  called  pigmentary^  Pigmentary  syph- 
syphilide  of  the  neck J      ilide  of  the  neck  p.  246 

The  grey  infiltrated  and  mammillated  lesions  of^  Acanthosis  nigri- 
acanthosis  nigricans J      cans P- 247 

The  molluscum  pendulum  observed  on  the  nfT/e"]  Molluscnm  pendu- 
of  old  people J      lum P- 247 

It  is  usual  to  class  actinomycotic  tumours  among' 

the  dermatological  lesions  and  we  shall   consider  .  . 

.,  •.;    .7  •  ■        ■        I  ■  I   tr  t  r  Actmomycosis     .   n.  248 

thon  with  this  region,  in  which  they  are  most  com-  ■'  -     ^^ 

inon J 

/  shall  finish  with  a  few  zuords  on  tertiary  ser-}  .    . 

piginous  syphilis,  ivhich  sometimes  occurs  in   thisy     .,: 

region 

The  semeiology  of  glands  of  the  neck  will  next 

be  considered  zvith  the  sub-occipital  glands  of  the 

impetigo  of  Bockhart  and  of  phitiriasis;  zcith  the 

sterno-mastoid  gland  of  chancre  of  the  tonsil,  etc. 
With    the    retro-cervical    glands    of    secondary^ 

syphilis '.J P-  ^5^ 

IVith  the  lateral  cervical  glands  of  scrofula p.  251 

With  the  submaxillary  glands  of  lingual  cancer p.  252 

And  the  subhyoid  gland  of  chancre  of  the  tongue p.  252 

FLEAS.      BUGS.      MOSQUITOES. 

The  region  of  the  neck  is  one  of  the  regions  most  frequently 
attacked  by  parasites,  such  as  fleas,  bugs,  mosquitoes,  caterpil- 
lars, etc. 


p.  250 

Semeiology  o  f 
glands  of  the 
neck p.  250 


THE    NECK.  243 

The  flea-bite  forms  a  red  areola  a  few  millimetres  in  diameter 
centred  with  a  red  point  of  puncture. 

The  mosquito-bite  is  an  oblong  oval  papule,  resembling  a  nettle 
sting.  It  is  intensified  by  scratching  and  the  central  puncture 
appears  as  a  scarcely  visible  pink  spot. 

The  bug-bite  often  resembles  that  of  the  mosquito  and  presents 
a  reddish  violet  point  of  puncture,  with  a  red  areola  like  the  flea- 
bite. 

On  the  neck  of  the  shirt  may  be  found  black  punctiform  spots 
which  are  the  traces  left  by  the  flea  or  bug. 

The  treatment  is  almost  nil.  A  drop  of  strong  carbolic  acid  (5 
per  cent)  relieves  the  itching,  and  ointments  of  carbolic  acid  or 
guaiacol  have  been  recommended. 

PUDIC    ERYTHEMA. 

Certain  persons,  especially  young  girls,  on  the  slightest  emotion, 
or  when  they  undress,  present  sudden  patches  of  redness,  dissem- 
inated over  the  neck  and  chest.  They  form  large  irregular  blotches 
with  clearly  defined  margins.  They  do  not  project  above  the  skin 
and  must  not  be  confounded  with  dermographism.  This  condition 
indicates  excitation  of  the  nervous  and  vaso-motor  systems.  It 
requires  no  treatment  and  only  requires  mention  to  avoid  errors  of 
diagnosis, 

DERMOGRAPHISM. 

The  neck  is  a  region  of  predilection  for  urticarial  reactions. 

It  is  especially  a  region  where  dermographism  has  its  maximum 
intensity.  This  is  a  cutaneous  urticarial  reaction  due  to  traumatism, 
especially  by  the  clothes.  It  forms  long  trails  of  urticarial  swelling, 
partially  surrounding  the  neck  and  often  disposed  in  several  rows. 
The  diagnosis  is  certified  by  the  finger  nail  applied  to  the  region, 
which  causes  the  affection  to  appear  in  a  few  minutes. 

The  treatment  is  palliative  and  consists  in  the  application  of  car- 
bolic and  menthol  ointments,  or  glycerine  of  starch  and  resorcine : — 

Glycerine       40  grammes  ji 

Starch 15         "  3iii 

Resorcine ■ 

Tartaric  acid -  i  gramme  gr.  12 

Menthol 


244  THE    NECK. 

High  frequency  treatment  may  be  prescribed  when  the  arterial 
tension  is  above  normal,  and  by  lowering  this  may  diminish  the 
most  disagreeable  functional  symptoms  of  this  peculiar  condition. 
But  this  is  not  always  the  rule. 

URTICARIA. 

Urticaria  may  be  a  recurrent  affection,  or  accidental.  When 
recurrent  it  is  attributed  without  proof  to  the  absorption  of  intes- 
tinal toxins,  or  to  defective  function  of  the  liver  and  kidneys.  It  is 
seen,  however,  in  patients  who  appear  normal  in  all  respects.  In 
women  the  attacks  are  repeated  monthly  before  the  periods. 

In  other  cases  it  is  due  to  indigestion,  caused  by  mussels,  oysters, 
shell-fish,  tainted  food,  etc.  In  this  case  the  neck  is  affected,  but 
not  more  than  other  parts  of  the  body. 

Urticaria  consists  of  a  large  number  of  flat  papules,  from  a  fifth 
to  two-fifths  of  an  inch  in  diameter,  oval,  irregularly  scattered  and 
more  or  less  confluent  in  different  regions. 

The  papules  are  white  or  pale  lilac  in  colour,  very  pruritic  and 
intensified  by  scratching.  In  certain  cases  the  centre  of  the  papule 
is  occupied  by  a  minute  vesicle  which  is  ruptured  by  scratching. 
The  papule  lasts  from  4  hours  to  2  or  3  days,  and  the  crisis  of  urti- 
caria has  the  same  variable  duration. 

Local  treatment  is  the  same  as  for  dermographism.  Internal 
treatment  consists  in  supervision  of  the  ingesta,  to  avoid  those  which 
may  be  at  fault.  The  menstrual  function  should  be  regulated  when 
it  is  irregular  or  retarded,  with  capsules  of  apiol  twice  a  day,  or 
when  there  is  painful  menstruation  by  ovarian  extract  for  ten  days 
before  the  periods. 

Urticaria  will  be  also  considered  with  the  general  dermatoses 
<P-  531)- 

ERYTHEMA    MULTIFORME. 

The  neck  is  one  of  the  three  common  regions  in  which  the  lesions 
of  polymorphous  erythema  occur;  the  two  others  being  the  wrists 
and  the  ankles. 

The  lesions  vary  in  number  and  dimensions  in  the  same  subject, 
and  in  appearance  according  to  age. 

They  arise  as  red  macules  which  become  oval  as  they  increase  in 


THE    NECK.  245 

size.  They  have  a  red  border  and  a  Hvid  centre,  and  thus  take  the 
characteristic  form  of  a  rosette.  They  never  desquamate  nor  dis- 
charge. They  are  developed  in  2  to  5  days ;  the  eruption  fades  from 
the  5th  or  6th  day  and  disappears  on  the  loth. 

Erythema  multiforme  has  been  explained  as  a  toxic  eruption,  but 
without  absolute  proof.  It  generally  follows  about  8  days  after  an 
infection,  which  is  usually  a  more  or  less  characteristic  angina.  The 
eruption  is  often  accompanied  by  malaise  and  articular  pains. 

The  treatment  is  the  same  as  for  benign  eruptive  fevers,  by  rest 
in  bed,  restricted  diet,  warm  drinks,  and  tonics  when  the  subject 
is  debilitated.    The  eruption  may  recur,  but  at  long  intervals. 

PITYRIASIS    ROSEA. 

Pityriasis  rosea  of  Gibcrt  is  not  specially  a  disease  of  the  neck,, 
but  develops  chiefly  on  the  trunk  and  the  first  segment  of  the  limbs. 
However,  it  has  the  peculiarity  of  presenting  its  last  elements  on 
the  neck,  and  does  not  extend  beyond  the  horizontal  line  of  the 
inferior  maxilla. 

The  elements  are  oval,  bistre  coloured  patches,  with  a  red  des- 
quamating border  The  squames  are  attached  at  the  border  and 
free  towards  the  centre  of  the  patch. 

The  etiology  of  this  affection  is  unknown  and  the  treatment  nil. 
Irritating  applications  should  be  avoided,  as  eczematisation  may  be 
produced.  The  duration  of  the  disease  on  the  neck  is  two  or  three 
weeks ;  the  total  duration  6  to  10  weeks.    It  never  recurs. 

ECZEMA    BY    PROPAGATION. 

The  antero-lateral  parts  of  the  neck  have  a  fine  skin  and  are 
among  the  first  to  be  attacked  by  placards  of  eczema  by  propaga- 
tion. Thus,  in  an  eczema  of  the  face  caused  by  dyes,  when  this  has 
a  tendency  to  extend,  the  neck  is  covered  with  red,  irregular 
patches,  often  composed  of  small  confluent  lesions  with  a  moist  sur- 
face. The  neck  is  also  aflFected  by  eczema  of  the  folds,  as  in  the 
elbow,  popliteal  space  and  groins. 

But  eczema  in  this  region  is  nearly  always  secondary  to  an 
eczema  of  neighbouring  parts ;  the  scalp,  face,  axillre  or  breast. 

It  is  difficult  to  formulate  a  treatment  for  these  forms  of  eczema^ 


246 


THE    NECK. 


which  may  be  of  very  different  nature.  Like  all  secondary  eczemas, 
they  may  be  treated  more  mildly  than  in  the  case  of  more  marked 
eczema  in  its  first  localisation.  Mild  ointments  and  pastes  are 
useful,  such  as  oxide  of  zinc  (10  parts  in  30  of  vaseline). 

PIGMENTARY   SYPHILIDE   OF   THE   NECK. 

This  occurs  on  the  antero-lateral  part  of  the  neck,  on  both  sides 
equally,  and  the  lesions  descend  as  far  as  the  clavicular  regions. 
The  lesions  are  very  easy  to  recognise  when  once  seen,  but  very 


Fig.  111.     Pigmentary  Syphilide   of  the  necJc. 
(Pournier's   patient.      St.    Louis   Hosp.    Museum,    No. 


39.) 


difficult  to  describe.  Most  often  they  resemble  what  a  roseola  would 
be  if  the  spots  were  bistre  instead  of  rose  colour.  On  a  pale  base  are 
seen  from  10  to  30  disseminated  large  grey  spots,  with  ill-defined 
borders.  At  other  times  there  is  a  leuco-malanoderma,  i.e..  paits 
paler  than  the  normal  skin  and  other  parts  bistre  coloured;  the 
whole  resembling  a  badly  applied  wash  of  diluted  Indian  ink.  This 
eruption,  the  origin  of  which  is  not  well  understood  and  described 
differently  by  authors,  appears  to  follow  closely  on  the  roseola.     It 


THE    NECK.  247 

is  thus  a  secondary  lesion,  and  is  more  common  in  women  than  in 
men.  It  persists  a  long  time  and  disappears  about  the  15th  month 
of  the  disease. 

Diagnosis  is  certified  by  the  retro-cervical  adenitis ;  sometimes  by 
the  roseola,  which  may  be  still  visible;  by  the  adenitis  secondary  to 
the  chancre;  by  parietal  alopecia  which  is  often  contemporary  with 
it,  and  by  the  recent  history  of  a  chancre. 

Local  treatment  is  nil  and  general  treatment  that  of  secondary 
syphilis  (p.  650). 

ACANTHOSIS    NIGRICANS. 

This  is  a  rare  dermatosis,  symptomatic  of  certain  cachexias, 
especially  the  cancerous  cachexia,  and  more  particularly  cancer  of 
the  stomach.  Its  proximate  cause  is  unknown.  Its  localisation  on 
the  neck  is  far  from  exclusive,  for  this  morbid  condition  first  attacks 
the  gums  (p.  42),  and  in  a  general  way  all  the  regions  of  the  skin 
Avith  folds  of  flexion  (p.  612). 

At  these  places  the  skin  becomes  ashy  grey  in  colour  and  presents 
singular  transformations.  It  is  thickened,  the  normal  folds  are 
accentuated,  and  the  surface  resembles  that  of  a  condyloma  seen 
under  a  lens.  It  is  covered  with  small  round  tumors,  of  various 
sizes  and  infinite  number ;  as  if  the  dermal  papillae  were  enlarged  so 
as  to  be  visible  to  the  eye.  These  give  a  mammillated  sensation  to 
the  touch  wherever  this  cutaneous  transformation  occurs.  This  con- 
dition is  chronic  and  progressive,  and  owing  to  its  cause,  ends  in 
death,  and  requires  no  local  treatment. 


MOLLUSCUM    PENDULUM. 

This  singular  lesion  is  constituted  by  a  small  sac  of  soft,  flabby, 
wrinkled  and  pedunculated  skin,  situated  on  a  healthy  and  normal 
surface. 

Molluscum  pendulum  is  a  persistent  lesion  which  increases  very 
slowly  and  is  never  transformed  into  a  malignant  tumour.  When 
situated  on  the  neck  they  generally  occur  in  men  or  women  who  have 
passed  the  40th  year  and  increase  in  number  and  size  with  age. 
Certain  individuals  whose  skin  is  prematurely  senile  show  them  from 
adult  age.    The  antero-lateral  surfaces  of  the  neck  may  present  from 


248 


THE    NECK. 


2  to  50  of  different  sizes,  the  largest  being  often  less  than  a  grain 
of  wheat  and  pedunculated,  and  affecting  the  diagrammatic  form  of 
tears. 

The  physician  is  only  consulted  for  these  lesions  by  men  who  are 
afraid  of  cancerous  degeneration,  and  by  women  who  regard  them 
as  unsightly.  The  treatment  is  simple,  and  consists  of  removal  by 
the  galvano-cautery. 


ACTINOMYCOSIS. 

Actinomycosis  is  a  disease  with  sub-cutaneous  tumours,  generally 
caused  by  the  Actinomyces  Boris,  but  sometimes  by  another  species 
of  the  same  family  of  fungus.  This  fungus  appears  to  live  on  grass 
in  the    saprophytic    state.      Inoculation    of    the    disease    has    often 

occured  bv  husks  of 
barley,  wheat  or  oats. 
The  point  of  entry  is 
the  throat ;  the  usual 
point  of  development 
the  sub-axillary  and 
lateral  cervical  regions. 
The  tumours  of  ac- 
tinomycosis have  a 
wooden  hardness  which 
very  few  other  tumours 
except  fibro-s  a  r  c  o  m  a 
and  schirrus  carcinoma 
can  simulate.  They 
slowly  attain  an  enor- 
mous size,  and  may 
cause  metastases,  proba- 
bly by  the  veins  and  not 
by  the  lymphatics.  The 
tumours  may  ulcerate ; 
one  part  of  the  mass  be- 
coming adherent  to  the 
skin,  opens  and  dis- 
charges a  little  pus,  m 
which  are  found  yellow  lumps,  the  size  of  barley  grains  and  of 
stony  hardness,  which  often  remain  impacted  in  the  orifice  of  the 
abscess. 


Fig.  112.     Actinomycous    of    the    neck    (after 
lUich). 


THE    NECK. 


249. 


These  yellow  grains  when  examined  by  crushing  between  two 
glass  slides,  fixation  by  acid  sublimate,  and  coloured  by  Gram's  stain, . 
show  a  parasite  formed  in  the  centre  by  a  felting  of  fine  violet.. 


Mg.  113.     Secundo-tertiary   circinate   eyphillde. , 
(Sabouraud's    patient.      Photo,    by    Noirfe.) 

mycelium  (1-3  to  1-2  fi),  surrounded  by  yellow  clubs  disposed  in 
rays  (axru'crs).    This  appearance  is  characteristic. 

Treatment  by  large  doses  of  iodine  of  potassium  sometimes 
succeeds  (i  to  10  grammes  daily)  ;  but  there  is  danger  of  cedema 
of  the  glottis.     Excision  is  rarely  practicable. 

The  action  of  the  X-ravs  is  unknown.     W'ithiout  intervention  the 


250 


THE    NECK. 


issue  is  fatal;  the  development  of  the  tumour  causes  obstruction 
of  the  pharynx,  or  compression  of  the  recurrent  laryngeal  nerve 
or  the  vagus  with  laryngeal  crisis  or  syncope.  Although  the  cachexia 
is  less  than  in  cancer,  it  takes  part  in  the  general  condition  in  which 
the  patient  succumbs. 

SERPIGINOUS   SYPHILIS. 

Apart  from  the  roseola  and  secondary  papules,  which  the  neck 
presents  like  other  parts  of  the  body,  secundo-tertiary  or  tertiary 
serpiginous  syphilides  may  develop.  They  occur  generally  in  the 
form  of  a  circular  or  polycircinate  border;  sometimes  as  copper 
coloured  corymbose  papules.  The  border  itself  is  composed  of 
papules  placed  together  in  the  form  of  a  band,  sometimes  covered 
with  adherent  psoriasiform  scales. 

The  lesions  are  of  extremely  slow  evolution,  lasting  for  months 
when  left  to  themselves  and  often  healing  on  one  side  while  they 
extend  on  the  other.  These  lesions  indicate  a  syphilis  of  long 
standing.  They  have  no  gravity  in  themselves,  but  prove  that  the 
disease  is  still  active  and  dangerous. 

Treatment  should  be  mixed  and  continued  till  the  lesions  have 
entirely  disappeared. 

SEMEIOLOGY  OF  THE  GLANDS  OF  THE  NECK. 

The  glands  of  the  neck  may  become  large  and  palpable  in  all 
regions  and  from  many  causes ;  nevertheless  there  are  certain  com- 
mon and  characteristic  types  of  adenitis  which  it  is  necessary  to  con- 
sider here. 

Occipital  Glands  in  impetigo  of  Bockhart  and  pediculosis  in 
children.  Whenever  a  child  presents  a  pustular  eruption  of 
the  scalp,  there  develops,  often  in  a  few  hours,  a  large  and  painful 
gland  on  each  side  of  the  occiput,  on  the  borders  of  the  scalp.  This 
gland  is  sensitive  enough  to  be  perceived  by  the  child. 

The  same  glands  are  seen,  in  phtiriasis  of  the  scalp  when  it  is 
accompanied  by  impetigo.  The  glands  never  suppurate,  but  persist 
as  long  as  the  eruption,  or  a  little  longer.  They  are  almost  pathog- 
nomic of  these  eruptions.  When  impetigo  of  Bockhart  (p.  183)  is 
recurrent,  which  is  the  rule,  each  eruption  is  heralded  by  the  glands 
several  hours  in  advance. 


THE    NECK.  _.5i 

Sterno-mastoid  Glands  of  chancre  of  the  tonsil.  This  is 
large,  unilateral  and  situated  under  the  centre  of  the  sterno-mastoid 
muscle.  All  the  glands  of  this  region  on  the  same  side  are  enlarged 
and  feel  like  almonds  when  rolled  under  the  finger ;  or  they  may  form 
a  common  mass.  But  the  indicator  gland  is  as  large  as  a  nut  and 
causes  a  projection  visible  to  the  eye.  It  is  hard,  slightly  painful 
and  difficult  to  palpate  owing  to  the  muscle  lying  over  it.  Examina- 
tion of  the  corresponding  tonsil  generally  reveals  the  chancre,  which 
persists  for  some  time  (p.  67).  The  patient  always  recollects  hav- 
ing had  a  unilateral  tonsillitis  which  lasted  four  or  five  weeks. 
There  is  hardly  any  doubt  as  to  the  diagnosis  even  when  the 
chancre  is  not  seen,  and  a  roseola  may  be  expected  in  a  short  time. 

Retro-cervical  Glands  in  Secondary  Syphilis.  At  the  second- 
ary period  all  the  lymphatic  glands  are  indurated  and  become  per- 
ceptible to  palpation.  Those  of  the  neck  are  especially  recognisable 
in  thin  women,  in  whom  they  are  visible  under  the  skin.  The  most 
marked  are  those  situated  at  the  back  of  the  neck.  They  feel  like 
almonds  to  the  touch ;  they  are  mobile,  nearly  painless,  and  of  the 
consistency  of  balls  of  India  rubber.  In  doubtful  cases  their  pres- 
ence is  of  great  importance.  Search  should  be  made  for  the  pig- 
mentary syphilide  of  the  neck,  glands  in  other  situations,  roseola 
and  other  corroborative  signs. 

Lateral  cervical  Glands  of  Scrofula.  Tuberculosis,  when  it 
affects  the  glands,  generally  attacks  the  anterior  cervical  glands, 
probably  because  the  naso-pharynx  is  a  common  port  of  entry  for 
the  tubercle  bacillus. 

The  sub-hyoid  gland  is  rarely  affected ;  the  sub-maxillary  glands 
in  general  slightly  enlarged,  and  the  sterno-mastoid  group  affected 
in  totality. 

All  the  glands  of  this  region  are  increased  in  size  and  agglomer- 
ated together.  They  are  painful,  or  at  least  sensitive.  This  condi- 
tion persists  for  years  and  becomes  slowly  aggravated.  The  pain 
varies  from  pain  on  pressure  to  continuous  pain  due  to  the  forma- 
tion of  an  abscess.  But  the  glandular  abscess  may  form  slowly 
without  any  pain  (cold  abscess),  ending  in  a  fistula  which  does  not 
heal.  The  fistulous  orifice  is  often  the  centre  of  a  chronic  fungoid 
lesion,  which  belongs  more  to  the  surgeon  than  to  the  dermatologist. 
Excision  of  tuberculous  glands  gives  very  mediocre  results,  and  the 
dermatologist  may  often  obtain  better  results  by  cauterisation  with 
•chloride  of  zinc   (i  in  i^),  or  with  the  two  cravons  of  nitrate  of 


252  THE    NECK. 

silver  and  metallic  zinc.  There  are  few  cases  which  are  not 
improved  by  this  method,  when  well  carried  out. 

Glands  in  cancer  of  the  lip  and  tongue.  An  epithelioma  of 
the  tip  of  the  tongue  or  the  lip  affects  the  sub-hyoid  gland.  It  is 
situated  in  the  centre  of  the  sub-maxillary  region  in  front  of  the 
hollow  of  the  hyoid  bone.  It  is  single,  the  size  of  a  marble,  as  hard 
as  wood,  and  mobile  for  a  considerable  time. 

Cancer  of  the  base  or  lateral  parts  of  the  tongue  affects  the  sub- 
maxillary glands,  which  can  be  felt  behind  and  below  the  angle  of 
the  jaw;  later  on  the  sterno-mastoid  glands  are  also  affected. 

It  is  premature  to  speak  of  the  value  of  the  X-rays  in  these  cases, 
which  requires  further  investigation.  It  is  a  question  whether  extir- 
pation of  the  glands  should  be  preferred  to  the  treatment  by  X-rays, 
using  radiotherapy  only  for  the  cicatrix.  Prudence  requires  that 
these  attempts  should  only  be  practised  on  inoperable  metastatic 
glands.  However,  we  must  admit  that  the  action  of  the  X-rays  is 
more  rapid  and  more  evident  on  the  glands  than  on  the  primary 
cancerous  lesions    (p.   33). 

Sub-hyoid  Gland  in  Chancre  of  the  tongue  and  lip.  The  sub- 
hyoid gland  is  the  indicator  of  chancre  of  the  tongue.  It  is  not  the 
gland  which  draws  attention  to  the  chancre,  but  the  chancre  which  is 
certified  by  examination  of  the  gland.  The  gland  is  single,  mobile, 
rolling  under  the  finger  like  a  ball  of  india  rubber,  of  which  it  has 
the  same  consistence.  Such  a  gland  co-existing  with  a  flat,  round 
exulceration  at  the  end  of  the  tongue,  of  less  than  two  months'  dura- 
tion, is  diagnostic  of  indurated  chancre. 


THE    AXILLA. 


Among  the  folds  of  flexion,  the  axilla  has  not  the  dermatological 
importance  of  the  fold  of  the  groin ;  yet  the  number  of  affections 
which  it  presents  with  predilection  is  considerable. 


Intertrigo  of  nurs- 
lings     p.  254 

Trichomycosis    of 
axilla      ....   p.  254 


P-25S 


-Hydrosadenitis   .   p.  255 


Eczema  of  adoles- 
cents     ....  p. 


256 


Scabies 


P-257 


The  infant  presents  axillary  intertrigo  or  eczema' 
in  connection  with  red  or  n'ecping  eruptions  of  the 
face   and   all   the   folds 

The  axillary  hairs  of  the  adult  are  often  covered 
by  a  sandy  deposit,  difficult  to  remove,  on  account 
of  which  the  dermatologist  may  be  consulted  . 

Phtiriasis  of  pubic  origin  may  be  met  zvith  in  the"] 
axilla,   and   its   treatment   may   present   some   rfj/- L Phtiriasis 
Acuities I 

The  skin  of  the  hairy  region  of  the  axilla  may' 
present  pustules  in  the  centre  of  papular  projec- 
tions, which  have  long  been  regarded  as  hydro- 
sadenitis   

Impetiginous  eczema  of  adolescents  has  a  strong 
predilection  for  the  folds  of  flexion  in  general.  It 
is  often  found  in  the  axillary  folds 

The  axilla  is  one  of  the  regions  zvhere  the  diag- 
nosis of  itch  is  most  easy,  for  the  acarus  often  mul- 
tiplies its  lesions  in  front  of  it 

There  is  a  ringzvorm  special  to  the  folds  of  flex-' 
ion,  more  common  in  the  groins  than  axillae,  but 
observed  with  a  certain  frequency  in  the  axillary 
fold 

Erythrasma,  more  common  in  the  inguinocrural 
fold,  presents  also  its  large,  round,  scurfy,  tawny 
placards  in  the  axilla 

Also  in  rare  cases,  desquamating  polycircinate 
lesions  with  a  double  erythematous  border,  occur 
in  the  axilla.  These  are  non-vesicular,  mycotic  in 
aspect;  but  the  parasite  remains  to  be  found  . 

Intertrigo    of   adults   is   common    in    the   axilla,\ 
either  in   its  simple  form J- Simple  intertrigo  p.  259 

Or  in  a   chronic  suppurating  form   with   hyper-') 
trophic      dermatitis  in   placards,  very   different   f^,  I  Chronic      intertri- 
chronic  intertrigo  of  the  inguinal  folds ^° P-  ^59 

Acanthosis  nigricans,  the  hyperplastic  dermatitis^ 
with  hyperpigmentation.  of  cachetics,  occurs  in  //,,  I  Acanthosis     nigri- 
axilla,  as  in  other  folds  of  flexion '      *^^"^ P-  260 


-Trichophytosis    .   p.  257 


Erythrasma 


Mjxosis     of     un- 
known nature  . 


P-257 


P-259 


254 


THE    AXILLA. 


The   same  with  Darter's   disease,  of  which  w^T  Follicular     psoro- 
shall  only  say  a  few  words J      spermosis      .    .   p.  260 

We  shall  end  this  chapter  by  taking  a  survey  of] 
the   semeiolgy    of    the    axillary   glands    and    thei*- 
adenitis,   which   is   more   or   less   characteristic   m 
general  affections  of  the  skin;  in  dermatoses  and 
in  lesions  of  the  breast  and  arms 


Semeiology  of  axil- 
lary glands  .    .   p.  260 


INTERTRIGO    OF    NURSLINGS. 

Intertrigo  of  the  axilla,  in  the  nursling,  is  much  less  common  than 
intertrigo  of  the  groin.  It  seldom  occurs  except  in  cases  where 
analogous  lesions  arise  at  the  same  time  in  all  the  folds.  It  then 
consists  of  remote  localisations  of  an  eczema  of  the  type  described 
above  on  the  face,  and  is  amenable  to  the  same  treatment  (p.  12). 

TRICHOMYCOSIS    OF    THE    AXILLA, 

In  adults  with  blonde  or  red  hair,  it  is  common  to  see  the  axillary 
hairs  curled  in  ringlets  which  give  to  the  fingers  a  gritty  sensation. 


Fig.  114. 


Hair   of   axilla   affected   with   nodular   trichomycosis,    magnified 
(Sarbourad's    preparation.     Photo,     by    Noire.  > 


The  hairs  appear,  to  the  naked  eye,  thickened  for  most  of  their 
length,  and  imbedded  in  a  yellow  segmented  concretion,  which  is 
very  adherent. 

Examined  microscopically,  this  appears  to  be  formed  by  refrac- 


THE   AXILLA.  255 

live,  homogeneous  crystalline  blocks,  probably  of  parasitic  origin. 
The  parasites  which  cause  this  condition  have  not  been  sufficiently 
studied. 

This  disease  is  more  common  in  persons  who  neglect  the  hygiene 
of  the  skin,  but  ma^^  occur  in  all  classes  of  society,  and  at  almost  any 
age.  It  is  seldom  accompanied  by  functional  symptoms  otherwise 
than  slight  itching  when  sweating  is  profuse.  It  often  co-exists 
with  abundant  red  sweat,  which  stains  the  linen. 

The  treatment  is  simple,  by  means  of  coaltar  soap,  or  alcoholic 
solution  of  saponified  coaltar  (i  in  7).  This  generally  causes  a 
cure  in  a  few  weeks,  but  recurrence  may  take  place. 

PHTHIRIASIS. 

The  phthirius  pubis  may  not  uncommonly  be  seen  in  the  axillse 
especially  in  hairy  men  in  whom  the  phthiriasis  becomes  generalised. 
The  crab  lice  and  nits  may  be  found  all  over  the  body,  and  colonies 
of  them  in  all  hairy  regions  such  as  the  axillfe. 

The  pullulation  may  be  enormous,  especially  in  those  who  are 
ignorant  of  being  infected.  In  others  the  parasites  are  not  so  numer- 
ous. Except  in  the  case  of  an  eczematous  subject  they  should  be 
treated  energetically.  The  axilla  is  painted  with  xylol  or  petroleum 
ether.  Every  parasite  touched  is  destroyed  by  the  liquid  penetrating 
the  respiratory  tubes.  All  the  hairy  regions  may  be  thus  treated 
and  immediately  followed  by  a  starch  bath  to  allay  the  smarting. 

When  the  skin  is  too  sensitive  to  stand  this  method,  simple  vase- 
line may  be  used  in  large  quantities,  which  impregnates  the  parasites 
in  the  same  way.  Mercurial  ointment  has  the  same  advantages,  but 
causes  cutaneous  irritation  in  the  axilhe  and  groins.  The  nits  are 
partly  dissolved  by  acids,  and  warm  vinegar  may  be  used  for  this 
j)urpose,  the  eggs  being  afterwards  removed  by  a  fine  comb. 

HYDROSADENITIS. 

This  name  is  still  incorrectly  applied  to  impetigo  of  Bockhart  of 
this  region.  The  lesions  consist  of  pustular  folliculitis,  always  more 
frequent,  more  coherent  and  more  painful  in  hairy  regions  than  in 
smooth  parts.  They  are  traumatic  or  spontaneous.  When  trau- 
matic they  follow  scabies  and  its  treatment ;  irritating  applications 


2SS  THE    AXILLA. 

■of  all  kinds  used  for  divers  purposes,  phthiriasis,  etc.  When  spon- 
taneous, they  are  similar  to  cases  occurring  in  the  beard,  pubis,  etc. 
They  may  accompany  a  diffuse  more  or  less  abundant  and  general- 
ised eruption  of  the  elements  all  over  the  body,  preceding  or  accom- 
panying a  true  furunculosis.  In  this  case  they  often  accompany 
hypoacidity  of  the  urine  and  hypophosphaturia.  ' 

The  lesions  consist  of  circumpilary  pustules,  of  a  greenish  yellow 
•colour,  more  or  less  agglomerated,  numerous  and  painful.  They 
often  present  a  characteristic  peripheral  raising  of  the  epidermis 
around  each  of  them,  which  gives  them  the  appearance  of  a  cupped 
papule  with  a  suppurating  centre.  The  implantation  of  the  hairs  of 
the  region  not  being  deep,  these  pustules  rarely  give  rise  to  true 
furuncle,  but  rather  to  a  series  of  abortive  boils. 

Local  treatment  comprises  epilation,  which  is  often  useful ;  starch 
poultices,  made  hot  and  applied  cold,  sprinkled  with  camphorated 
alcohol,  or  saturated  boric  alcohol ;  ointments  of  oxide  of  zinc, 
removed  daily  without  soap,  by  means  of  oil  of  almonds.  Treat- 
ment of  the  general  condition  should  not  be  neglected  whenever  this 
•appears  to  play  a  role  in  the  long  duration  of  regional  folliculitis. 

IMPETIGINOUS    ECZEMA. 

Impetiginous  eczema  of  adolescents,  when  very  pronounced  on  the 
face,  is  usually  accompanied  by  inguinal  and  axillary  lesions.  It  is 
■always  an  exudative  epidermatitis  of  extensive  area  occupying  the 
whole  axillary  region.  It  may  be  very  exudative  from  the  first, 
becoming  more  dry  and  desquamative  later  on,  in  benign  cases.  The 
subjacent  skin  is  very  red  during  the  whole  course  and  the  epider- 
matitis at  the  periphery  is  desquamating.  In  some  cases  it  is  com- 
plicated by  more  or  less  discrete  follicular  pustules.  It  is  difficult 
at  first  to  distinguish  between  primary  amicrobial  eczema,  strep- 
tococcic intertrigo  and  staphlococcic  pustulation ;  these  two  affec- 
tions occurring  secondarily  to  primary  amicrobial  lesions. 

The  local  treatment  of  this  affection  includes  two  distinct  phases : 
during  the  period  of  discharge  a  solution  of  nitrate  of  silver  is 
applied  (5-15  per  cent)  the  more  the  lesion  appears  eczematous  and 
the  less  intertriginous  (concomitant  with  lesions  of  the  face,  inner 
surface  of  the  thighs  and  arms,  etc.)  ;  and  solutions  of  sulphate  of 
zinc  ( I  per  cent)  the  more  the  lesion  is  intertriginous  and  tl-ke  less 
eczematous. 


THE    AXILLA.  257 

The  general  treatment,  like  that  of  all  eczemas,  is  obscure  (vide  p 
12). 

SCABIES. 

The  acartis  of  scabies  prefers  the  regions  where  the  skin  is  soft 
and  fine,  and  the  folds  of  flexion  fulfil  these  conditions  very  well. 
In  the  axillary  region,  the  acarus  prefers  the  anterior  region  of  the 
shoulder,  corresponding  to  the  seam  of  the  coat  sleeve,  to  the  axil- 
lary fold  itself.  In  this  region  few  vescicles  or  pustules  are  seen,  but 
many  parallel  and  vertical  excoriations  made  by  the  nails.  It  is 
rare  to  find  among  these  lesions  an  intact  burrow,  and  it  is  then  on 
the  costal  wall  of  the  axilla.  It  is  the  topography  of  these  axillary 
lesions,  rather  than  their  elementary  form,  which  suggests  the  idea 
of  scabies,  and  the  diagnosis  is  then  certified  by  lesions  of  the  hands, 
fingers,  penis,  etc.     For  the  treatment  see  p.  539. 

TRICHOPHYTOSIS. 

The  intertriginous  trichophytosis  which  causes  the  so-called 
eczema  marginatum  of  Hebra  will  be  studied  better  with  the  derma- 
toses of  the  inguino-crural  region.  It  is  found  in  the  axilla,  but 
less  often  than  in  the  inguinal  and  genital  regions. 

It  is  always  due  to  the  same  species  of  trichophyton,  the  sapro- 
phytic or  animal  origin  of  which  we  are  ignorant  ( Figs.  1 18  and  1 19) . 
It  always  assumes  the  same  form  of  large,  circular,  red  patches  with 
a  red  and  vesico-pustular  border.  The  patches  may  be  from  one  to 
two  inches  in  diameter  and  coalesce  to  form  large  polycylic  placards. 
They  are  often  symmetrical  and  chronic,  persisting  for  months  in 
the  same  place,  with  scarcely  any  functional  symptoms. 

The  treatment  is  that  of  all  ringworms  of  smooth  regions:  daily 
friction  with  tincture  of  iodine  (25  per  cent). 

It  is  easy  to  cure  and  only  recurs  when  the  treatment  has  not  been 
sufficiently  prolonged. 

ERYTHRASMA. 

Erythrasma  is  usually  an  inguinal  or  inguino-crural  dermatosis 
and  is  seen  only  exceptionally  in  the  axill-E,  on  one  or  both  sides. 
It  is  characterised  by  reddish  brown  patches,  circular  and  polvcyclic 
17 


258 


THE    AXILLA. 


by    fusion,    very    finely    desquamative,   non-vesicular,    of    indefinite 
duration,  easily  curable  and  often  recurrent.    It  is  almost  unknown 


Fig.  116.     Axillary    ringworm     (Trichophyton  intertrlginis). 
(Sarbourad's    patient.     Photo,    by    Noir6.) 

for  erythrasma  to  occur  in  the  axillae  without  erythrasma  in  the 
groins  (p.  265).  In  all  situations  it  is  amenable  to  the  same  treat- 
ment. 


THE   AXILLA.  259 

CIRCINATE  ERUPTIONS  OF  INDETERMINATE  NATURE. 

I  have  once  observed  an  affection  of  the  axilla  of  special  char- 
acter, which  appeared  to  be  a  dermatomycosis ;  but  no  particular 
parasite  was  discovered. 

This  case  occurred  in  a  young  girl  of  18  or  20,  in  the  form  of 
two  large  patches  occupying  the  two  axillae  and  extending  in  front 
of  them.  Each  patch  was  large,  yellow,  scurfy,  polycircinate  with 
a  sharp  border,  but  of  double  contour,  the  two  concentric  n-^rginal 
lines  being  of  a  dark  red  colour  and  separated  by  nearly  2-3  ths  of 
an  inch  of  almost  healthy  skin. 

This  eruption  caused  secondary  patches  on  the  neck  and  the  bend 
of  the  elbow  on  one  side  only,  while  both  axillae  were  affected. 

Successive  treatment  by  tincture  of  iodine,  nitrate  of  silver,  oil 
of  cade  and  pyrogallic  acid  caused  no  improvement;  but  a  cure  was 
obtained  in  three  or  four  weeks  by  the  daily  application  of  chrysaro- 
bin  ointment  (i  in  30). 

This  application  has  also  given  me  the  best  results  in  the  dermato- 
mycosis of  the  Far  East  (Japan,  Siam,  Cochinchina,  Madagascar), 
and  should  be  tried  in  all  cases  of  rebellious  mycosis. 

INTERTRIGO. 

I  have  treated  of  intertrigo  in  general  with  retro-auricular  Inter- 
trigo. The  origin  of  all  intertrigos  is  the  same:  they  are  always 
streptococcic  dermatites.  Intertrigo  is  announced  by  a  burning  sensa- 
tion and  smarting  on  washing.  On  examination,  the  fold  is  red, 
moist,  with  a  superficial  erosive  lesion,  which  the  fold  separates 
into  two  equal  and  corresponding  parts.  In  more  acute  cases  the 
lesion  is  increased  by  the  addition  of  small  flat  vesicles  with  turbid 
contents,  which  are  transformed  by  scratching  into  erosions  which 
enlarge  and  become  fused  together.  An  acute  attack  of  intertrigo  is 
easily  curable;  a  chronic  intertrigo  often  recurs  after  cure. 

The  best  applications  for  benign  intertrigo  are  tincture  of  iodine 
(5  per  cent)  or  alcoholic  solution  of  saponified  coaltar  (i  in  7). 
In  more  chronic  cases  nitrate  of  silver  (i  in  20)  may  be  applied, 
followed  by  zinc  paste  (i  in  5). 

CHRONIC    INTERTRIGO. 

Chronic  intertrigo  of  the  axilla  does  not  always  correspond  clin- 
icallv  to  that  of  the  groin ;  the  latter  occurs  at  advanced  age,  in  obese 


260  THE    AXILLA. 

persons  with  hyperacid  urine ;  that  of  the  axilla  is  observed  in  young 
persons  after  an  eruption  of  boils,  which  is  common  in  this  situa- 
tion. A  chronic  suppurative  superficial  dermatitis  is  thus  constituted 
in  the  axilla,  complicated  with  follicular  abscess  and  vegetations, 
isolated  or  in  placards,  which  somewhat  resemble  the  condylomata 
of  chronic  suppurations  of  the  anus  and  vulva. 

The  treatment  consists  first  in  absolute  cleanliness,  local  baths  and 
weak  lotions  of  nitrate  of  silver  (2  per  cent)  or  sulphate  of  zinc 
(i  per  cent).  By  this  means  the  most  apparent  symptoms  are 
improved  in  a  few  days.  In  the  interval  of  applications,  isolating 
dressings  of  pastes  or  powders  may  be  useful.  When  the  pseudo- 
condylomatous  state  of  hypertrophic  dermatitis  is  constituted,  appli- 
cations of  perchloride  of  iron  rapidly  reduce  the  exuberant  granu- 
lations and  hasten  the  cure. 

ACANTHOSIS    NIGRICANS. 

This  hyperplastic  and  hyperpigmentary  dermatitis,  which  espe- 
cially accompanies  the  cancerous  cachexia,  is  especially  seen  round 
the  neck,  on  the  gums,  on  the  tongue  and  in  all  the  folds  of  flexion, 
including  the  axilla.  It  has  no  peculiar  sign  in  this  region.  This 
condition  has  been  described  elsewhere  and  is  well  shown  in  the 
figure  (Fig.  116). 

DARIER'S    DISEASE. 

I  have  already  spoken  of  follicular  psorospermosis  of  the  face 
(p.  25)  and  I  shall  refer  to  it  again  in  studying  the  dermatoses  of 
the  inguinal  regions  (p.  268),  where  it  often  attains  a  considerable 
development.    In  the  axilla  it  is  rarely  well  marked. 

SEMEIOLOGY    OF    THE    AXILLARY    GLANDS. 

The  axillary  glands  furnish  indications  for  diagnosis  and  prog- 
nosis in  diseases  of  the  breast  rather  than  in  those  of  the  arms. 

A  group  of  axillary  ganglia  may  be  observed  in  the  child  in  cases 
of  eczema  of  the  folds,  and  in  prurigo  of  Hehra  (p.  549)  ;  in  senile 
prurigo  (p.  551)  ;  in  ichthyosis  histrix  and  the  infections  to  which 
it  gives  rise  (p.  518)  ;  in  mycosis  fungoides  and  in  lymphadenitis. 
But  the  glands  of  the  axilla  are  of  special  value  in  chancre  of  the 


THE    AXILLA. 


26 1 


breast,  cancer  of  the  breast,  Pagct's  disease  of  llie  nipple,  chronic 
eczema  of  the  breast,  pustular  scabies,  etc. 

As  each  of  these  diseases  is  described  elsewhere  I  shall  only  say 
a  few  words  concerning  each  of  the  forms  of  adenitis  and  their  par- 
ticular signs. 

Satellite  Gland  of  Chancre  of  the  breast.  This  is  single, 
large,  hard,  resistant  and  painless  or  nearly  so.  Its  size  distinguishes 


Fig.  116.     Acanthosis    nigricans    of    Axilla. 
CJeanselme  s   patient.      Photo    by    Noir§.  > 


it  from  the  odier  glands  and  it  is  usually  found  on  the  costal  border 
of  the  axilla.  Its  presence  supports  the  diagnosis  of  chancre  of  the 
breast  in  the  case  of  a  recent,  indurated,  painless  sore  of  the  nip- 
ple or  areola,  without  discharge. 

The  Glandular  Pleiades  of  Secondary  Syphilis.  This  can  be 
felt  in  the  axilla  as  in  all  other  regions  where  the  glands  can  be 
papulated.     There  are  generally  three  distinct  glands,   somewhat 


262  THE   AXILLA. 

enlarged,  hard,  distinct  and  painless,  situated  along  the  thoracic  wall 
more  or  less  deeply  in  the  axilla. 

The  Axillary  Glands  in  tumours  of  the  breast.  As  in  the  case 
of  all  glands  in  the  vicinity  of  neoplasms,  these  indicate  a  grave 
prognosis  and  a  tendency  to  generalisation.  They  are  of  great 
importance  in  tumours  of  the  breast,  Paget' s  disease  and  ulcerated 
cancers.  Palpation  must  be  made  with  great  care,  whenever  the 
diagnosis  of  a  chronic  ulceration  or  a  tumour  of  the  breast  is  in 
question. 

Radiotherapy  of  the  axillary  glands  generally  gives  excellent 
results,  applied  at  the  same  time  as  radiotherapy  of  the  tumour, 
every  three  weeks.  The  method  is  too  recent,  however,  to  speak 
definitely  of  the  duration  of  the  improvement. 

In  chronic  simple  dermatitis  of  the  nipple  and  areola,  chronic 
eczema,  scabies,  pruritus,  etc.,  the  glands  are  all  equally  affected 
and  generally  united  in  a  mammillated  tangible  mass.  The  volume 
of  each  gland  may  be  doubled  or  tripled,  and  in  spare  persons  they 
may  be  seen  projecting  under  the  skin.  They  are  especially  evident 
in  severe  senile  pruritus  and  in  mycosis  fungoides. 


THE  INGUINAL  REGION. 


The  dermatological  pathology  of  the  groin  in-" 
eludes  intertrigo  of  the  folds  of  the  region,  in  in- 
fants   


And  intertrigo  in  the  adult 


In  the  adult  the  groin  may  present  the  dark  rcd.^ 
squamous    discs    of    crythrasma ! 

.    .   .  And  herpes   circinata 

Indurated  chancre  may  he  observed  at  the  base 
of  the  penis,  and  cutaneous  mucous  patches  in 
the  inguinal  fold 

Glandular  soft  chancre  will  be  treated  with  the' 
semeiology  of  the  glands  of  the  region 

The  inguinal  region  is  also  one  of  the  seats  of 
predilection  of  Darier's   disease 

There  is  a  senile,  inguinal,  intertriginous  der- 
matitis, a  little  different  from  true  intertrigo  of  the 
same  situation  in  the  adult 

The  dermatological  semeiology  of  the  inguinal 
glands  is  complex,  for  the  fold  of  the  groin  is 
the  lymphatic  centre  of  three  regions.-  of  the  foot 
and  its  septic  wounds  and  lymphangitis  of  tlie  leg^ 

.  .  .  of  the  genital  organs:  hard  chancre,  soft^ 
chancre  and  bubo J 

.  ,  .  of  the  anus  with  the  adenitis  of  anah 
chancre,  etc J 

There  are  diseases  in  which  the  three  groups  of 
glands  are  affected  at  the  same  time;  the  prurigo 
of  Hebra,  senile  pruritus,  premycotic  pruritus, 
and  mycosis  fungoides 


Inguinal  inter- 
trigo of  suck- 
lings     p.  263 

Intertrigo  of 
adults p.  263 

Erythrasma      .    .   p.  265 

Inguinal  trich- 
ophytosis      .    .   p.  266 


Syphilis 


p.  267 


Inguinal  bubo  and 
phagedena     .    .   p.  267 

Vegetating  follicu- 
lar psorosperm- 
osis      p.  268 

Senile  intertrig- 
inous dermatitis  p.  268 

Sub-inguinal  aden- 
itis   p.  269 


Genital  adenitis     .  p.  270 
Anal   adenitis    .     .  p.  271 


Complete  inguinal 
adenitis      ...  p.  272 


INTERTRIGO    OF    SUCKLINGS. 

The  skin  of  the  folds  of  flexion  is  fragile.  It  is  badly  aerated  and 
often  remains  moist,  leading  to  epidermic  maceration  and  the  irrita- 
tive lesions  which  follow  it. 

In  the  suckling  the  causes  of  maceration  are  numerous.  It 
appears  that  the  irritative  lesions  of  the  folds  only  occur  when  the 
faeces  and  urine  are  not  normal,  as  in  enteritis,  etc.  Hence  the 
intestine  should  first  be  treated  in  such  cases.    When  there  is  glairy 


264  THE    INGUINAL    REGION. 

enteritis  the  diet  should  be  restricted  and  small  doses  of  calomel 
given  (i-5th  grain)  ;  two  doses  every  half  hour  in  sugar  of  milk. 
The  local  treatment  when  the  lesions  are  moist  consists  of  creams 
and  pastes : — 

(1)  Oxide  of  zinc 7  grammes  5ii 

Vaseline -> 

Lanoline L  aa     10  "  3i 

Rose  water J 

(2)  Oxide  of  zinc 18  parts 

Carbonate  of  bismuth 2 

Vaseline 20        " 

Powders  of  lycopodium  are  also  useful :  its  only  objection  is  its 
price. 

When  the  lesions  discharge,  we  have  to  deal,  not  with  a  localised 
process,  but  with  a  general  eczema  of  sucklings  for  which  a  milk 
diet  is  not  suited  (p.  4).  In  such  cases,  before  applying  creams 
or  powders,  and  whenever  the  linen  is  changed,  oxygenated  water 
should  be  apphed  to  the  lesions. 

The  prognosis  is  always  good,  but  the  affection  may  last  6  months. 

INTERTRIGO  OF  ADULTS. 

In  the  adult  also  the  fold  of  the  groin  is  par  excellence  the  region 
of  intertrigo.    It  occurs  in  three  degrees. 

(i)  In  the  first  it  consists  of  a  red  fissure,  limited  to  part  of  the 
fold ;  this  fissure  persists  or  recurs  for  some  time ;  it  causes  itching 
and  smarting  after  washing. 

(2)  In  the  second  degree  the  same  lesion  is  more  marked,  and 
on  both  sides  of  the  fissure  are  two  red  surfaces  of  epidermis  in 
apposition.  On  this  surface  the  horny  epidermis  is  detached  and 
macerated.  This  condition  exists  in  the  whole  fold  of  the  groin 
on  both  sides  and  in  the  fold  between  the  buttocks. 

(3)  In  the  third  degree  the  lesions  are  wider,  more  extensive  and 
more  exudative ;  and  around  them  may  be  seen,  even  at  points  where 
the  skin  is  not  in  contact,  small  disseminated  lesions,  called  eczema 
or  eczematisation  by  some ;  seborrhoeids  by  others.  Sometimes  even 
in  the  young  adult,  similar  lesions  co-exist  in  the  hypogastric  fold. 

These  lesions  are  tenacious  and  chronic  in  proportion  to  the  sur- 
face aflFected.    Thev  have  been  attributed  to  the  rheumatic  diathesis, 


THE    INGUINAL    REGION. 


265 


which  signifies  nothing  till  this  diathesis  is  defined.  Apart  from 
obesity,  which  causes  irritation  of  the  folds  of  flexion,  we  are  ignor- 
ant of  the  local  conditions  which  predispose  to  this  state. 

The  lesion  of  intertrigo  is  always  microbial;  it  always  contains 
the  streptococcus  which  can  be  cultivated  bv  the  usual  methods 
(p.  8). 

The  mildest  degree  of  intertrigo  may  be  treated  with  tincture  of 
iodine  in  Eau  de  Cologne  (5  per  cent)  or  saponified  coaltar  in 
Eau  de  Cologne  (10  per  cent). 

More  severe  cases  may  be  painted  wath  nitrate  of  silver  (i  in  15), 
followed  by  a  protective  paste  which  must  be  washed  oflF  before  each 
fresh  application.  In  rebellious  cases  permanganate  of  potash  ( i  in 
1000  to  I  in  5000)  is  useful. 


\ 


\a 


\ 


ERYTHRASMA. 

Erythrasma  may  occur  in  the  axilla,  but  its  seat  of  election  is  the 
inguinal  fold.     It  is  characterised  by  a  brownish  red  patch  from  2 

to  3  inches  in  di- 
ameter, finely  squa- 
mous, always  local- 
ised to  the  fold  of 
the  groin,  but  ex- 
tending t  ow  a  r  d  s 
the  thigh. 

The  patches  of 
erythrasma  are  al- 
ways circular  and 
often  occur  as  sev- 
c  r  a  1  intersecting 
circles.  They  have 
the  same  appear- 
ance on  the  whole 
surface,  in  the  cen- 
tre and  at  the  mar- 
gins. The  dermatosis  which  erythrasma  most  resembles  is  ring- 
worm, but  the  latter  always  shows,  in  these  regions,  a  border  which 
is  redder  than  the  centre  of  the  lesion,  and  this  border  is  slightly 
raised  and  always  vesicular.  Nothing  of  this  kind  is  seen  in  ery- 
thrasma. 


Fig.  117. 


Extemporary   preparation   of 
thrasma.     Obj.     1-12.     Ocul. 


squame    of    Ery- 
Leitz. 


(Sarbouraud's    preparation.      Drawing    by    Gillet.) 


266 


THE    INGUINAL    REGION. 


Erythrasma  occurs  nearly  always  in  the  two  groins  more  or  less 
unequally ;  it  also  affects  the  scrotum  over  a  surface  corresponding 
to  the  affected  surface  of  the  thigh. 

In  very  marked  cases  it  occupies  both  groins,  and  axillae,  and  some- 
times occurs  on  the  thigh,  in  large  patches  the  size  of  half  a  crown. 
The  affection  is  much  more  common  in  men  than  in  women ;  it  is 
monomorphous,  chronic,  of  indefinite  duration,  and  has  a  tendency 
to  recur  after  treatment. 

The  parasite  causing  the  affection  is  the  Microsporiim  miniitis- 
simiDii  of  Von  Barespriing,  a  cryptogamic  parasite  of  extreme  fine- 
ness, the  dimensions  of  which  approach  those  of  bacteria.  It  may  be 
demonstrated  by  collecting  the  squames  by  scratching  with  a  glass 
slide,  clearing  with  ether,  and  staining  with  carbolised  thionine  (i 
in  200),  or  any  basic  aniline  stain.  The  parasite  is  seen  among  the 
squames  (Fig.  117). 

The  treatment  of  erythrasma  must  be  continued  for  some  time  to 
give  definite  results.  Tincture  of  iodine  ( i  in  10)  or  permanganate 
of  potash  (i  in  1000)  are  the  best  remedies.  Daily  application 
causes  the  patches  to  disappear  in  4  or  5  days,  and  a  cure  is  effected 
in  15  or  20  days.    Possible  recurrence  must  be  watched  for. 

TRICHOPHYTOSIS. 


Ringworm  of  the  groin  is  very  common  in  both  men  and  women, 
and  is  confounded  by  many  dermatologists  with  erythrasma.    It  has 

the  same  situation,  the 
same  form  in  circular 
patches  2  to  4  inches  in 
diameter,    and    the    same 


Fie.  118.     Squame     of     inguinal     trichophyton     (400        Fig- U9.      Trichophyton  plicatlle  of 
diameters).       (Sabouraud's   preparation.      Photo.  intertriglnous  ringworm.     Cul- 

by   Noire  )  ^^^^  °"  gelose  peptone. 


THE    INGUKMAL    REGION.  zdj 

polycircinate  disposition ;  but  tlie  trichophytic  patches  are  larger 
(Fig.  115),  more  polycyclic  and  more  irregular  than  the  erythras- 
mic  patches ;  they  are  moreover  distinguished  by  the  fact  that  the 
erythrasmic  patch  is  uniformly  brownish  red,  while  the  trichophy- 
tic patch  is  brighter  red  with  a  finely  vesicular  margin,  the  vesicles 
containing  slightly  turbid  fluid.  Microscopic  examinations  of  this 
fluid  or  of  the  squames  in  the  centre  of  the  patch  shows  the  sep- 
tate mycelial  elements  characteristic  of  herpes  circinata.  Here  the 
mycelium  is  relatively  thin,  and  the  septa  wide  apart  (Fig.  118). 

Culture  of  this  parasite  shows  always  the  same  species  of  tri- 
chophyton (Fig.  119).  This  species  is  only  met  with  in  intertrigi- 
nous  inguino-scrotal,  vulvar,  axillary,  or  sub-mammary  ring- 
worms (p.  493). 

The  treatment  is  the  same  as  for  erythrasma,  but  requires 
stronger  applications : — 

(i)  Tincture  of  iodine  . 
Spirit  of  lavender  . 
Alcohol,  60  per  cent 

(2)   Lanoline 

Distilled   water    .    . 
Metallic   iodine 
Iodide    of    potassi 


} 

sium  J 


20  grammes 

3ii 

.        ID 

3i 

.      80 

5i 

aa     20  grammes 

3ss 

aa     40  centigrammes 

gr.  5 

Intertriginous  ringworm  is  easier  to  cure  and  less  recurrent  than 
erythrasma, 

SYPHILIS. 

Syphilis  may  be  represented  by  hard  chancre  of  the  root  of  the 
penis ;  rarely  in  the  groin.  It  is  usually  oval  and  sometimes  nearly 
an  inch  in  its  larger  diameter.  The  induration  may  be  very  pro- 
nounced and  cartilaginous.  It  is  always  flat  with  an  eroded  non- 
exudative  surface.  It  is  often  surrounded  by  a  flat  epidermic  cush- 
ion.   Its  progress  and  resolution  are  normal. 

The  inguino-scrotal  or  vulvar  region  often  presents  secondary 
svphilides  of  the  florid  exulcerated  papular  type,  called  cutaneous 
mucous  tubercles.  They  are  sometimes  quasi-confluent  and  bathed 
in  a  foetid  sanious  liquid.  Diagnosis  is  made  by  exclusion,  as  no 
other  morbid  condition  resembles  them.  The  presence  of  chancre, 
enlarged  glands  and  general  secondary  eruption,  etc.,  generally 
make  the  diagnosis  clear. 


26S  THE    INGUINAL    REGION. 

DARTER'S    DISEASE. 

Vegetating  follicular  psorospermosis  has  one  of  its  chief  localisa- 
tions in  the  groin  and  lower  part  of  the  abdomen. 

The  elementary  lesion  is  a  conical  brown  crust  with  a  flat  surface 
occupying  and  dilating  the  pilo-sebaceous  orifices.  The  latter  occupy 
the  centre  of  a  papule,  these  papules  sometimes  coalescing  in  groups, 
at  other  times  remaining  distinct.  They  are  soft  in  consistence  and 
of  a  grey  colour. 

The  disease  develops  in  the  seborrhoeic  regions  of  the  face,  chest 
and  back  (medio-thorax)  ;  in  the  axillae  and  groins,  and  on  the 
hands,  etc.  In  the  groins  the  elementary  lesions  are  confluent.  They 
become  more  scattered  and  diminish  in  size  and  number  away  from 
the  centre  of  the  region.  The  disease  generally  commences  gradu- 
ally in  adolescence ;  remains  chronic,  and  never  undergoes  resolution 
without  treatment. 

The  treatment  is  symptomatic  and  not  etiological.  Since  the 
cause  of  the  disease  is  unknown  it  is  palliative  and  not  curative.  It 
is  exclusively  external  and  consists  of  reducing  and  keratolytic 
reaeents : — 


(i)  Precipitated  Sulphur 

Cinnabar     

Salicylic  acid    .    .    .    . 

Resorcine 

Lanoline 

Vaseline 


-  aa       I  gramme  gr.  i6 


■  aa       15  grammes  5ss 


.    aa     I  gramme  gr.  24 


(2)   Oil  of  cade 10  grammes  3iv 

Ichthyol   

Resorcine 

Oil   of  birch 

Lanoline 20  grammes  •>'} 

The  first  is  stronger  than  the  second.  The  dose  of  these  reagents 
must  be  varied  according  to  the  cutaneous  reaction  of  the  subject. 
Prolonged  baths  containing  6  ounces  of  bicarbonate  of  soda  and  3 
ounces  of  gelatine  to  60  gallons  of  water  also  give  good  results  as 
adjuvants  to  the  external  applications. 

SENILE     INTERTRIGINOUS     DERMATITIS. 

Old  people,  especially  when  obese,  often  present  a  dermatitis  of 
the  folds  which  differs  considerably  from  the  intertrigo  of  the  same 


THE    INGUINAL    REGION.  269 

situation  in  younger  people.  This  occupies  the  transverse  supra- 
pubic, the  two  inguinal  and  the  intergluteal  folds.  It  is  very  inflam- 
matory, with  very  marked  functional  symptoms.  The  fold  may  be 
fissured  and  very  painful.  On  both  sides  of  the  fissure  are  two  more 
or  less  eroded  or  dry  surfaces;  always  of  a  purple  colour  like  the 
lees  of  wine  and  sometimes  as  large  as  the  hand. 

I  have  seen  this  dermatitis  in  a  gouty  subject  with  tophi,  tendinous 
contractions  and  severe  attacks  of  gout ;  in  a  man  affected  with  drv 
arthritis  and  sublaxation  of  the  knee ;  in  a  woman  with  senile  morbus 
coxae,  and  at  other  times  without  articular  manifestations,  but  nearly 
always  in  subjects  with  hyperacid  urine,  and  of  an  advanced  age. 

This  intertriginous  dermatitis,  which  ma}'  or  may  not  be  infected 
with  streptococci,  appears  to  me  to  differ  clinically  from  intertrigo, 
both  by  its  intensity  and  its  chronicity.  and  the  cure  is  often  incom- 
plete. The  hyperacidity  of  the  urine  must  be  treated  by  a  season 
at  Vichy,  by  phosphate  and  bicarbonate  of  soda,  h)drate  of  magne- 
sia, etc.     Local  treatment  should  be  mild,  for  fear  of  irritation. 

Alcohol  with  traces  of  iodine  is  an  application  which  causes  much 
smarting  at  first,  but  relief  afterwards.  Picric  acid  (i  in  500)  or 
permanganate  of  potassium  ( i  in  5000  to  i  in  10,000)  give  similar 
results. 

Between  the  applications  very  mild  creams  are  interposed  between 
the  folds  of  the  skin,  by  strips  of  fine  linen  impregnated  wath  fresh 
cold  cream  or  fresh  lard  without  any  active  agent. 

DERMATOLOGICAL      SEMEIOLOGY      OF      THE      INGUINAL 

GLANDS. 

The  fold  of  the  groin  contains  the  lymphatic  glandular  centres 
of  three  regions :  the  lower  limb,  the  genital  organs,  and  the  arms. 

(i)  The  group  of  glands  corresponding  to  the  lymphatic  net- 
work of  the  lower  limb  is  situated  at  the  point  of  junction  of  the 
mternal  saphenous  vein  wath  the  femoral.  It  is  here  that  the  painful 
glandular  swellings  are  produced,  which  accompany  septic  injuries 
to  the  feet,  foul  wounds,  punctures,  cuts,  peri-ungual  suppuration, 
abscess,  traumatic  suppurating  phlyctenules,  lymphangitis  due  to 
badly  cut  corns;  suppuration  of  burs?e  around  chronic  articular 
deformities,  bunions,  etc.  These  lesions  do  not  properly  belong  to 
the  domain  of  dermatology. 


270  THE    INGUINAL    REGION. 

Ecthymatous  ulcerations,  ulcer  of  the  leg,  and  wounds  of  the  leg 
are  accompanied,  the  first  always,  the  others  frequently,  by  lymph- 
angitis. Chronic  ulcer  of  the  leg  is  accompanied  by  repeated  lymph- 
angitis, which  constitute  true  erysipelas  (p.  306)  ;  the  glands  being 
not  popliteal  but  saphenous. 

These  simple  inflammatory  adentites  have  only  a  secondary  im- 
portance in  the  syndromes  which  they  accompany.  They  seldom 
suppurate,  and  nearly  always  end  in  resolution. 

(2)  Adenitis  corresponding  to  genital  lesions  occupies  the  inner 
two-thirds  of  the  groin.  The  inguinal  group  of  glands  extends  for 
about  four  inches  and  includes  5  to  7  distinct  glands. 

Inflammatory  suppurative  balanitis,  simple  or  gonorrhoeal,  is  only 
accompanied  by  simple  and  transient  glandular  reaction. 

The  adenitis  of  indurated  chancre  includes  two  elements.  The 
"pleiad"  of  Ricord  and  the  indicator  gland.  All  the  glands  are 
enlarged  and  indurated  and  have  the  special  consistence  which  is 
compared  to  balls  of  india  rubber.  These  glands  are  movable  and 
roll  under  the  finger;  and  in  thin  subjects  they  are  visible  to  the  eye. 
They  are  not  sensitive,  nor  even  painful  to  pressure.  They  occur 
nearly  equally  in  both  groins.  The  secondary  syphilitic  polyadenitis 
which,  becoming  generalised  in  all  the  glands  of  the  body,  constitutes 
the  secondary  poly-micro-adenitis  of  some  authors. 

Moreover,  on  the  same  side  as  the  chancre  is  seen  a  gland  double 
the  size  of  the  others;  it  is  also  rather  softer  and  more  sensitive. 
This  is  the  indicator  or  satellite  gland  of  hard  chancre,  which  Ricord 
facetiously  termed  the  "Prefect  of  the  groin."  No  treatment  is 
required  for  syphilitic  glands.  In  3  to  6  months  the  indicator  gland 
becomes  the  same  size  as  the  others,  and  in  10  to  18  months  the  poly- 
adenitis disappears  and  the  glands  return  to  their  normal  size.  But 
several  months  after  the  roseola,  palpation  of  the  glands,  and 
especially  of  the  inguinal  glands,  will  furnish  evidence  in  the  diagno- 
sis of  a  doubtful  case  of  syphilis. 

SUPPURATING   BUBO.     SOFT   CHANCRE. 

Sometimes  in  the  course  of  evolution  of  soft  chancre  of  the  pre- 
puce or  glans  (p.  421),  one  of  the  glands  of  the  groin  becomes  swol- 
len and  presents  inflammatory  symptoms,  including  spontaneous 
pain,  increased  on  pressure.  This  bubo  enlarges  and  becomes  adhe- 
rent to  the  reddened  skin.     This  becomes  purple   and  ulcerates, 


THE    INGUINAL    REGION. 


271 


exposing  the  suppurating  gland.  The  ulcer  is  deep  and  irregular, 
with  ragged  borders.  The  pus  is  thick  and  sometimes  streaked  with 
blood.  The  evolution  is  slowly  reparatory,  and  ends  after  two 
months  in  the  formation  of  a  large  radiating  cicatrix  which  is  suffi- 
cient for  retrospective  diagnosis  of  the  affection  which  caused  it. 

The  swelling  when  once  formed  always  ends  in  ulceration;  it  is 
not  a  simple  adenitis,  but  a  glandular  soft  chancre.  It  thus  requires 
treatment  like  soft  chancre  by  the  most  active  caustics  and  antisep- 
tics. The  method  of  aspirating  the  ulcers  with  a  syringe,  and  inject- 
ing camphorated  ether  or  iodoform,  may  destroy  the  bacillus  of 


Flgr.  120.     Phagedenic  bubo.      (Du  Castel's  patient. 
Hosp.   Museum,  No.   2050.) 


St.  liOiiis 


Ducrey  or  prevent  opening  of  the  abscess;  this  allows  spontaneous 
absorption  because  the  life  of  the  bacillus  is  short.  The  glandular 
chancre,  when  opened,  may  be  treated  by  iodoform  ointment  ( i  in 
20)  or  sub-carbonate  of  iron  ointment  (i  in  40)  ;  camphorated  tan- 
nin, etc. 

Phagedena  of  the  glandular  chancre  has  been  observed  like  that 
of  soft  chancre  in  all  situations  (Fig.  120). 

The  treatment  is  the  same  (p.  421). 

3.  Glands  corresponding  to  Anal  Lesions.  These  occupy 
the  external  third  of  the  groin.  They  are  best  palpated  in  the  stand- 
ing position.  When  palpation  of  the  inner  two-thirds  of  the  groin 
is  negative,  palpation  of  the  outer  third  should  be  made  carefully. 


272  THE    INGUINAL    REGION. 

Chronic  inflammations  of  the  arms :  haemorrhoids,  fistula  and  fis- 
sures, anal  tuberculosis,  etc.,  may  cause  swelling  of  the  inguinal 
glands.  But  when  the  indicator  gland  is  single  and  as  large  as  a 
nut,  it  certifies  an  indurated  chancre  of  the  anus. 

4.  All  three  groups  of  inguinal  glands  are  enlarged  in  a 
certain  number  of  affections.  In  prurigo  of  Hcbra  in  the  adolescent, 
for  example,  they  may  be  visible  to  the  eye  without  palpation. 

Also  in  senile  pruritus,  when  they  are  smaller  and  not  so  hard. 
They  are  equally  affected  in  premycotic  pruritus,  mycosis  fungoidcs 
and  leucaemia.  But  in  all  these  cases  the  adenitis  is  only  an  epiphe- 
nomenon,  insufficient  in  itself  to  settle  the  diagnosis. 


THE    THIGH. 

The  thigh  has,  strictly  speaking,  no  dermatosis  peciihar  to  itself; 
nevertheless,  it  is  a  region  affected  by  many  forms  of  dermatosis. 

The  thigh  may  be  divided  into  two  unequal  segments.  The  upper 
segment,  comprising  one-third  of  the  antero-internal  surface,  pre- 
sents the  affections  of  the  groin  ;  while  the  other  segment,  consist- 
ing of  the  lower  two-thirds  and  the  external  surface,  has  not  the  same 
individuality. 

The  superior  internal  segment  shozcs  the  devel-^ 

J-    ■        ■     ,    ■  s     .  ■  Llntertnero      ...    p.  274. 

opment   of  inguinal  intertrigo J  *  t      /t 

The    aberrant   placards    of   erythrasina,    circular,^ 

J       J  j:     1  IKrythrasma      .    .   0.274 

red  and  finely  squamous j       -^  i      /-+ 

The  ornamental  designs  of  inguinal  trichophytosis    Trichophytosis    .    p.  275 
The  internal  surface   of  the   thigh  is  a  scat  of\ 
predilection  for  pruritus |  Pruritus     ....   p.  275 

And  for  the  lesions  zvhich  folloiv  or  accompany  it    Lichenisation  .    .   p.  275 

The  inner  surface  of  the   thigh  presents  a  soft^ 
skin    which    easily    develops    moist    eczema,    and  V'E.cze.mz      ....   p.  277 
eczema  in  patches J 

Many  traumatisms,  especially  mcdicamcntal,  may]  Traumatic   dernia- 
give  rise  to  a  peculiar  form  of  dermatitis  .    .    .    .j      titis P- 277 

Keratosis  pilaris,  zvith  its  horny  follicular  eleva-^ 
tions,   occupies    especially    the    external   surface    0/^  Keratosis   pilaris   p.  277 
the  thigh J 

The  internal  surface  of  the  thigh  also  presents']  ^^     .  ,.     . 

,    ,.„         ,'  .         '       ■    .■        ^   ■  (  ,     ,  IVarix.        Varicose 

varices  of  different  sices,  projecting,  painful,  chron-  r      , 

ically  inflamed,  with  diverse  changes  in  the  skin   .    .J  ■     •    •    ■  p.    70 

Ichthyosis  covers  the  zvhole  surface  of  the  thigh,-^ 
especially  the  external,  with  a  hyperkeratotic  ctiirassj'^'^^^^^y'^^^^     ■    ■    ■   P- 278 

The   desquamation    of   the   bed-ridden,   formerly^ 
knozvn   as  pityriasis   tabescentium,  also   occurs  o;i  l^^squamation     of 
the  thigh J      ^^e  bed-ridden    p.  279 

Other  eruptions  occur  on  all  parts  of  the  thigh.] 

For  instance,  the  purple  papular  streaks  of  lichen  V  Lichen  planus     .   p.  279 

planus  of  Erasmus   Wilson J 

And  the  pustules  of  furunculosis Furunculosis    .    .   p.  280 

I  may  here  mention  that  the  thigh  is  one  of  the  places  where  the 

polymorphous   eruptions   of  Duhring's  disease    (p.   605).   and   the 

efflorescence  of  anaesthetic  leprosy  (p.  657)  are  most  often  observed. 


274  THE    THIGH. 

INTERTRIGO. 

Intertrigo  of  the  groin,  in  its  exudative  and  semi-crustaceous 
forms,  may  extend  to  the  neighbouring  regions.  It  then  invades  the 
antero-internal  surface  of  the  thigh,  forming,  in  addition  to  the  pri- 
mary intertriginous  placard  which  has  the  fold  of  the  groin  for  its 
axis,  placards  identical  with  those  to  impetiginous  eczema.  These 
patches  are  about  an  inch  in  diameter,  irregularly  rounded,  denuded 
of  the  horny  epidermis,  exudative  and  covered  with  crusts,  which 
have  the  appearance  of  a  yellow  crystalline  powder  like  resin.  These 
are  secondary  patches  of  streptococcic  impetigo  sown  around  the 
primary  streptococcic  lesions  of  intertrigo. 

The  same  treatment  is  applicable  to  both  the  primary  and  sec- 
ondary lesions:  viz.,  applications  of  nitrate  of  silver  (i  in  15)  and 
zinc  ointment. 

Chronic  Hyperplastic  Intertrigo.  Along  with  the  intertrigos 
I  may  mention,  as  in  the  case  of  the  axilla  (p.  259),  a  morbid  type 
which  is  not  well  described  by  any  author.  Objectively,  this  hyper- 
plastic intertriginous  dermatitis  resembles  patches  of  lichenisation ; 
the  neuro-dermatitis  of  certain  authors.  The  skin  of  the  inguinal  or 
genito-crural  fold  is  thickened,  hyperplastic,  hard  and  divided  into 
lozenges  by  small  quadrilateral  folds ;  but,  while  in  lichenised  patches 
the  surface  of  the  lozenges  is  flat,  smooth  and  almost  varnished ; 
in  this  case  each  lozenge  forms  a  swelling  like  a  cappadine,  with  a 
moist  surface,  neither  smooth  nor  varnished,  from  which  epidermic 
debris  can  be  detached  by  the  finger.  This  condition  results  from 
maceration  and  chronic  intertriginous  infection,  which  is  seen  in 
many  cases  when  the  size  of  the  male  genitals  is  increased  (\^arico- 
cele,  hydrocele,  etc.)  ;  or  in  women  when  a  muco-purulent  vaginal 
discharge  constantly  soils  the  thigh  (vaginitis,  gonorrhcEa,  diabetes). 
Pruritis  is  always  very  pronounced. 

The  treatment  consists  in  suppression  of  the  cause  when  possible. 
Locally,  weak  solutions  of  tincture  of  iodine  in  alcohol  ( 10  per  cent), 
alternating  with  zinc  paste  give  the  best  results. 

ERYTHRASMA. 

Erythrasma  of  the  thigh  does  not  occur  without  inguinal  ery- 
thrasma;   but  the   large,   circular,   russet  coloured,   dry  and  finely 


THE   THIGH.  275 

scurfy  patches  of  erythrasma,  although  originating  in  the  groin^ 
have  a  greater  tendency  to  develop  on  the  thigh  than  on  the  hypo- 
gastrium.  There  may  also  be  seen  large  erythrasmic  patches  from 
two  to  three  inches  in  diameter  on  the  inner  surface  of  the  thigh, 
which  only  touch  the  groin  in  a  small  part  of  their  extent. 

In  this  case  there  are  often  small  discs  of  erythrasma,  as  large  as 
half  a  crown,  dissemminated  on  the  thigh,  sometimes  as  far  as  the 
lower  third,  isolated  from  the  parent  eruption  from  which  they 
proceed. 

Their  nature  is  certified  by  microscopic  examination,  and  the 
treatment  is  the  same  as  for  erythrasma  in  general  (p.  266). 


INGUINAL   TRICHOPHYTOSIS. 

Inguinal  trichophytosis  may,  like  erythrasma,  develop  on  the  inner 
surface  of  the  thigh.  It  only  occurs  as  an  extension  of  the  inguinal 
lesion  and  has  no  symptomatic  or  therapeutic  peculiarity  in  this, 
region. 

PRURITUS   AND   LICHENISATION. 

Pruritus  does  not  usually  affect  the  groin,  but  the  root  of  the 
thigh  on  its  inner  surface,  immediately  below  the  fold.  Here  is 
observed  the  chronic  infiltration  of  the  skin  with  papillary  hyper- 
trophy, formerly  called  lichen  circnmscriptns.  This  is  now  named 
by  different  authors,  neurodermatitis,  lichenised  prurigo,  lichenisa- 
tion  or  lichen  ification. 

The  skin  is  raised,  thickened  and  pachydermatous;  us  fold  is 
double  or  treble  the  thickness  of  normal  skin ;  the  surface  is  smooth, 
shiny  and  formed  of  lozenge  shaped  flat  papules,  separated  by  linear 
intervals,  the  whole  forming  a  parquet  or  pavement.  Around  these 
placards  are  the  pruritic  lesions  of  prurigo,  with  acuminated  papules 
truncated  by  scratching;  each  covered  wath  a  minute,  red,  conical 
scab. 

In  some  cases  eczematisation  and  exudation  take  the  place  of 
lichenisation.  In  all  cases  the  lesions  are  of  indefinite  duration  and 
their  functional  symptoms — smarting  and  itching — excessively  dis- 
tressing. 


276 


THE    THIGH. 


Hitherto  there  have  been  two  methods  for  the  treatment  of  these 
lesions :  external  anti-priiriginous  applications  such  as : — 


\ 


'%■ 


Fig.  131.     Chronic    dermatitis.     Pruriginous   eczematisation   of  the    vulva   and   Inner 

surface    of   the   thigh. 
(Broeq's   patient.      Photo,    by   Sottas.) 

Glycerine  of  starch 40  grammes     5J 

Resorcine 

Tartaric   acid !-ia     i   gramme       gr.  12 


Menthol 

or  plasters  of  cod  liver  oil,  combined  with  treatment  of  the  nervous 
system  by  warm  douches,  which  have  a  percussive  and  sedative 
action. 

Nowadays  we  can  treat  the  pruritus  by  high  frequency  or  by  the 
X-rays ;  and  the  remaining  lesions  by  reducing  applications.  These 
methods  give  far  better  results. 


Oil  of  cade 
Resorcine  . 
Ichthyol    .    , 
Oil  of  birch 
Lanoline    . 


10  grammes     .t  iv 


I   gramme       gr.  24 


20  grammes     3j 


THE   THIGH.  2y7 

EXUDATIVE    ECZEMA. 

Eczema  of  regions  where  the  skin  is  fine,  as  in  the  folds  of  flexion, 
as  well  as  the  type  of  eczema  of  adolescents,  which  we  have  already 
described  in  different  localisations,  may  be  observed  on  the  inner 
surface  of  the  thigh.  It  may  occur  in  a  diffuse  form,  with  large 
placards  12  inches  or  more  across,  or  in  localised  nummular  patches: 
round,  slightly  raised,  exudative,  papyraceous,  with  yellow  scabs, 
and  often  intersected  or  fissured. 

These  lesions  may  be  persistent  or  recurrent,  but  have  no  par- 
ticular prognostic  value.  The  prognosis  and  treatment  are  included 
in  those  of  the  general  affection. 

TRAUMATIC    DERMATITIS. 

On  the  thigh  traumatic  dermatitis  often  assumes  a  peculiar  figured 
appearance,  which  resembles  in  some  respects  a  parasitic  dermatosis. 
They  form  a  red,  dry  dermatitis,  composed  of  rounded  efflorescences,, 
segmented  like  wheels  or  open  flowers.  Sometimes  there  occurs  a 
placard  composed  of  4  or  5  similar  efflorescences ;  at  other  times  the 
whole  thigh  is  covered  with  similar  lesions,  separated  by  placards 
of  red,  dry  and  more  diffuse  dermatitis. 

These  lesions  are  usually  traumatic,  following  scabies,  or  medica- 
ments such  as  styrax,  naphthol,  balsam  of  Peru,  sulphur,  sulphur 
baths,  strong  alkaline  baths,  soft  soap,  turpentine,  etc.,  etc. 

This  dermatitis  may  follow  other  lesions,  such  as  pityriasis  rosea, 
which  have  been  treated  by  irritants.  The  treatment  lies  in  suppres- 
sion of  the  cause.  Warm  baths  with  starch  or  gelatine,  and  zinc 
paste  may  be  applied  locally. 

KERATOSIS    PILARIS. 

Keratosis  or  ichthyosis  pilaris  is  a  morbid  condition  of  the  exten- 
sor surfaces  of  the  limbs;  especially  the  back  of  the  arms  and  the 
external  surface  of  the  thigh.  It  arises  at  about  the  age  of  14  and 
persists  during  life,  more  or  less  marked  in  different  cases.  The 
skin  of  the  whole  region  is  purple,  owing  to  bad  circulation ;  the 
local  temperature  is  diminished ;  and  the  skin  appears  rough  owing 
to  the  hyperkeratosis  obstructing  the  hair  follicles.  Very  often  a 
hair  is  found  rolled  up  in  the  horny  plug  which  it  could  not  pene- 
trate. 


278  THE    THIGH. 

The  cause  of  this  condition  is  unknown  and  the  treatment  is  pal- 
liative.   Keratolytic  agents  are  often  borne  in  large  doses : — 

Salicylic  acid 1 

Resorcine >^     5  grammes  aa     gr.  8o 

Vaseline 30  "  5j 

When  the  medicament  is  active,  it  destroys  the  horny  epidermis 
of  the  region,  which  becomes  wrinkled  and  assumes  the  appearance 
of  a  cobweb  pasted  on  the  skin. 

When  it  is  wished  to  increase  the  power  of  the  active  drug  a 
layer  of  soft  soap  is  previously  applied  to  the  skin  for  a  quarter  of 
an  hour.  Inversely,  when  the  medicament  is  too  active,  it  may  be 
attenuated  with  applications  of  zinc  ointment. 


VARIX   AND   VARICOSE   DERMATOSES. 

Varices  of  the  thigh  are  common  in  the  upper  and  lower  thirds 
of  the  saphenous  vein  and  give  rise  to  the  "medusa  head"  appear- 
ance. The  sub-cutaneous  varicosities  give  rise  to  a  series  of  changes 
in  the  skin  covering  them.  This  becomes  dark  coloured  or  villous, 
by  hyperpigmentation  and  hyperplasia  of  the  papillae.  This  lesion 
may  cause  a  local  hyperplasia  and  a  hyperkeratosis  similar  to  that  of 
homy  lichen  planus. 

The  lesions  are  almost  irreducible  because  their  cause  is  .per- 
sistent. They  may  be  improved  by  cleanliness  of  the  skin ;  moderate 
compression  of  the  varicose  region  by  an  elastic  tissue,  permeable 
to  air ;  dressings  of  zinc  cream,  applied  by  massage  and  covered 
with  aseptic  lint,  under  the  elastic  tissue. 

ICHTHYOSIS. 

Ichthyosis  is  a  congenital  malformation  which  consists  in  non- 
dehiscence  of  the  stratum  corneum  when  matvire;  i.e.,  when  the 
horny  cells  have  lost  their  nucleus. 

The  skin  appears  covered,  as  with  a  rough  coat,  by  the  thickened, 
coarse  and  wrinkled  horny  epidermis,  which  on  account  of  its  per- 
manence absorbs  all  the  dust  and  becomes  of  a  grey  or  black  colour. 
In  benign  cases  the  skin  appears  clothed  with  cobwebs,  and  is  rough 
to  the  touch ;  in  more  severe  cases  it  feels  like  a  file.     Eventually. 


THE    THIGH.  ^  279 

especially  in  regions  where  the  horny  epidermis  is  normally  thick, 
as  on  the  hands,  hyperkeratosis  is  combined  with  a  quasi-papilloma- 
tous  condition  of  the  skin,  which  we  shall  study  later  on  (p.  354- 
518).  On  the  external  surface  of  each  limb  the  ichthyosis  is  more 
pronounced  than  on  the  internal  surface  and  the  folds  of  flexion  are 
free,  even  in  very  marked  cases.  The  diagnosis  of  this  deformity 
is  easy,  if  only  by  its  permanence.  It  is  pronounced  in  early  infancy 
and  persists  during  life.  Treatment  is  simply  palliative,  by  the 
following  ointments,  combined  with  frequent  gelatine  and  alkaline 
baths. 

(i)  Glycerine  of  starch 5j 

Resorcine gr.  5 

(2)   Oxide  of  zinc 

Vaseline      ,  , 

...  y     equal  parts 

Lanoline ' 

Oil  or  almonds   o: 

DESQUAMATION    OF   THE    BEDRIDDEN. 

This  is  a  symptom,  and  not  a  disease.  Even  the  healthy  skin 
exfoliates  perpetually  by  an  insensible  scurf.  In  a  bedridden 
patient,  without  proper  care  of  the  skin,  flakes  of  old  detached  epi- 
dermis adhere  to  the  new  skin,  and  this  becomes  especially  marked 
under  a  permanent  occlusive  dressing.  This  pityriasis  tabescentinm 
(Seborrhcea  tabescentinm  of  Hebra)  has  no  pathological  interest. 
Applications  of  an  inert  fat,  combined  with  soaping,  will  restore  the 
skin  to  its  normal  condition. 


LICHEN    PLANUS. 

The  region  of  the  thigh  is  one  of  those  where  lichen  planus  devel- 
ops its  most  florid  elements  and  its  most  confluent  eruption. 

As  elsewhere,  the  slow,  progressive,  more  or  less  pruriginous 
eruption  begins  by  a  condition  in  which  the  elements  are  scanty, 
and  the  diagnosis  is  difficult  for  a  non-specialist.  Here  and  there 
occur  red,  flat,  smooth,  shiny  elements,  grouped  in  numerous  small 
papules  round  a  larger  central  one.  Gradually  the  second  period 
arrives,  in  which  the  elements  are  coherent,  like  those  of  measles 
which  has  well  "come  out.'"  At  this  stage  numerous  red  spots 
and  streaks  are  situated  close  together  on  a  healthy  skin,  simulating 


28o  .  THE    THIGH. 

an  exanthem.  On  close  examination  the  papules  are  almost  conflu- 
ent and  when  they  form  placards,  these  are  striated  with  white 
lines  "setting"  the  papules,  which  is  very  characteristic. 

Later  on  a  third  stage  follows,  in  which  each  papule  is  replaced  by 
a  pigmentary  spot  of  the  same  shape,  which  in  its  turn  becomes 
effaced. 

Lichen  planus  has  no  specific  treatment;  the  treatment  is  purely 
symptomatic  and  directed  against  the  pruritus,  by  means  of  baths, 
warm  douches,  high-frequency,  ointments,  creams  and  glycerines ; 
resorcine,  tartaric  acid  and  menthol  (p.  553}. 

FURUNCULOSIS. 

Furunculosis,  even  when  it  tends  to  become  generalised,  pre- 
serves regions  of  election.  These  are  especially  the  buttocks  and 
shoulders ;  but  the  thigh  has  a  tendency  to  develop,  in  blonde  per- 
sons, follicular,  staphylococcic  pustules,  which  form  impetigo  of 
Bock  hart  on  the  scalp,  and  which  may  abort  or  become  true  fur- 
uncle (p.  185). 

In  these  cases  the  patient  should  take  a  diet  containing  much 
phosphorous,  and  even  phosphoric  acid;  20  to  40  drops  a  day  in 
water  or  beer. 

At  the  same  time  each  pustular  element  is  treated  by  epilation  of 
the  central  hair,  followed  by  the  application  to  the  open  pustule  of  a 
drop  of  tincture  of  iodine,  camphorated  alcohol,  or  saturated  alco- 
holic boric  acid.  Puncture  with  the  galvano-cautery  is  also  useful 
in  aborting  the  boils  at  their  commencement. 


THE  ARM. 


The  region  of  the  arm  presents  very  few  special  dermatoses. 


It  is  the  region  zvhere  vaccination  is  practised,-^ 
and  we  shall  here  deal  with  vaccinia j 

We  shall  next  study  its  benign  complications ; 
generalised  vaccinia;  secondary  vaccinia  by  auto- 
inoculation;  false  vaccinia;  vaccinal  roseola,  and 
vaccinal  erythema  multiforme 

The  severe  complications  demand  a  special  para- 
graph for  each.  In  the  first  place  comes  vaccinal 
erysipelas 

Next   ulcerative   vaccinia,   zvhich   is   occasionally^ 
contagious    and    epidemic J 

Finally,   syphilitic   vaccinal    chancre   which   may) 
be  inoculated  in  series J 

The   arm   is   the   seat   of   election   for   keratosis'} 
pilaris,    especially    in   young   girls J 

Its  external  surface  is  one  of  the  regions  where') 
ichthyosis    may    be    pronounced J 

The  arm,  like  the  thigh,  is  a  region  where  dif-' 
ferent  kinds  of  scurfy  spots  are  often  seen,  incor- 
rectly grouped  together  under  the  name  of  sebor- 
rho:ids 

The  arm  is  the  region  for  the  application  of 
blisters,  which  may  require  treatment;  and  on  their 
cicatrices  tubercle  and  epithelioma  may  develop, 
which   require   treatment   without   delay 


Vaccinia    ....   p.  281 

Benign  complica- 
tions of  vac- 
cinia       p. 282 

Vaccinal  erysipe- 
las    p.  282 

Ulcerative  vac- 
cinia     p.  283 

Vaccinal  syphilis  p.  283 
Keratosis  pilaris  p.  284 
Ichthyosis     ...   p.  284 

-  Seborrhoeids     .    .  p.  286 


Blisters  and  their 
cicatrices   ...   p.  286 


VACCINIA. 


"When  inoculation  has  been  practised  from  arm  to  arm,  or  directly 
from  the  calf  (the  most  efficacious  method  by  far,  in  refractory 
cases),  in  a  healthy  subject,  vigorous  and  in  good  condition,  who 
has  not  been  vaccinated  for  10  years,  nor  variolised  in  the  5  to  10 
preceding  years,  one  observes  on  the  third  or  fourth  day  a  small  red 
papule ;  on  the  fifth  day  the  papule  becomes  a  vesicle  and  is  sur- 
rounded by  a  red  zone.  On  the  sixth  day  a  small  pustule  appears 
which  enlarges  and  becomes  umbilicated  on  the  7th  or  8th  day,  at 
which  time  it  is  complete  and  of  a  dull  white  colour,  or  by  reflec- 


282  THE    ARM. 

tion  silvery  and  pearly.  From  the  8th  to  the  loth  day  it  enlarges 
still  more,  generally  causing  itching,  and  sometimes  slight  glandu- 
lar swelling.  Most  commonly  in  the  newly  born,  most  of  the  inocu- 
lations are  accompanied  by  pustules,  sometimes  in  pairs.  Febrile 
reaction,  studied  by  Von  Jaksch  and  Erich  Peiper,  appears  6  times 
out  of  30,  from  the  4th  to  7th  day.  Rarely  it  reaches  38°  and  even 
40°,  from  superposed  infection.  The  fever  is  always  of  the  remittent 
type.  It  is  not  generally  observed  in  children  when  revaccinated. 
The  pulse  always  corresponds  to  the  rise  of  temperature.  During 
the  vaccinal  period  it  is  common  to  see  the  increase  in  weight 
diminish  or  cease  in  the  infant  at  the  breast.  From  the  loth  to  the 
13th  day  the  pustule  becomes  dry.  From  the  13th  to  the  30th  day 
the  scab  is  detached,  leaving  a  corrugated  surface."     {H.  Daucher.) 

BENIGN    COMPLICATIONS    OF    VACCINIA. 

In  rare  cases  there  occurs  a  generalised  vaccinia  with  the  appear- 
ance of  20,  50  or  100  pustules  all  over  the  body.  Cases  also  occur 
of  secondary  vaccinia,  by  auto-inoculation,  appearing  from  the  8th 
to  the  13th  day,  after  the  first  inoculation.  The  false  vaccinia,  or 
better,  vaccinoid,  is  a  small  abortive  pustule  following  vaccination 
in  a  child  quasi-refractory  to  the  first  inoculation.  Even  in  this 
attenuated  form  immunity  is  conferred  against  variola.  The  vac- 
cinal roseola  is  apyretic;  appears  in  the  4th  to  nth  day  after  vac- 
cination and  lasts  two  or  three  days.  Vaccinal  erythema  multiforme 
and  urticaria  are  rareties. 

VACCINAL     ERYSIPELAS. 

Vaccination  may  cause  erysipelas  in  various  ways.  The  vaccine 
lymph  may  be  taken  from  human  vaccinia  complicated  with  impeti- 
ginous super-infection ;  or  the  instrument  used  may  be  contami- 
nated ;  or  the  skin  may  have  been  insufficiently  cleansed  in  a  child 
with  streptococcic  lesions ;  or  the  infection  may  be  caused  by  the 
point  of  inoculation  being  left  unprotected  in  a  hospital  room  con- 
taining patients  with  erysipelas. 

These  cases  are  benign  or  severe,  and  some  are  followed  by  fatal 
septicaemia.  More  commonly  the  erysipelas  develops  like  erysipe- 
las of  the  face  and  requires  the  same  treatment. 


THE    ARM. 


283 


ULCERATIVE  AND  GANGRENOUS    VACCINIA. 

Cases  of  ulcerative  vaccinia  may 
])Q  cases  of  ulcerative  ecthyma  su- 
peradded to  vaccinia.  The  ulcera- 
tion is  deep,  from  half  an  inch  to 
an  inch  in  diameter,  and  is  accom- 
panied by  intense  peripheral  inflam- 
mation, lymphangitis,  painful 
glands,  which  may  suppurate,  and 
more  or  less  severe  general  symp- 
toms. 

Some  authors  have  described 
and  figured  rare  cases  of  multiple 
gangrene  of  the  skin,  spontaneous 
or  secondary.  These  cases  are,  no 
doubt,  comparable  to  that  which 
we  shall  describe  later  on  under 
the  name  of  spontaneous  gangrene 
of  the  scrotum  (p.  428).  But  in 
this  case  the  points  of  gangrene  are 
multiple,  arising  together  like  the 
elements  of  an  eruptive  fever  and 
developing  with  severe  general 
symptoms.  The  issue  is  generally 
fatal.  The  tre^-tment  should  be  that 
of  phagedena  in  general. 

VACCINAL    SYPHILIS. 

Vaccinal  chancre  appears  from 
the  loth  to  the  20th  day  after  vac- 
cination and  increases  during  the 
following  15  days.  It  is  excoriated 
and  sometimes  covered  with  a  thin 
scab,  but  never  ulcerated.  The 
erosion  of  the  surface  may  sur- 
round the  indurated  and  projecting 
chancre.  The  chancre  is  like  a  flat 
saucer,  and  its  induration  is  very 
perceptible.  Local  reaction  is 
slight ;  the  satellite  gland  is  pain- 


V 


< 


Fig.  122.  Gangrenous  eruption  after 
vaccination.  (.1.  Hutchinson's  pa- 
tient. Medico-chirurglcal  transac- 
tior".' 


284  THE    ARM. 

less  and  there  is  neither  lymphangitis  nor  fever.     Roseola  and  sec- 
ondary lesions  occur  later  on. 


KERATOSIS     PILARIS. 

The  external  and  posterior  part,  or  back  of  the  arm,  is  the  seat 
of  election  of  this  cutaneous  anomaly.  It  is  probably  of  congenital 
origin,  but  becomes  more  pronounced  from  puberty  to  adult  age; 
the  elementary  lesion  consists  of  a  small  cone  of  hyperkeratosis  occu- 
pying each  hair  follicle. 

The  skin  is  generally  cold  and  rather  purple  from  deficient  circu- 
lation, and  rough  to  the  touch.  Each  hair  follicle,  often  marked  by 
a  purple  point,  is  either  filled  or  surrounded  by  a  slightly  projecting 
horny  mass,  which  is  conical  when  the  orifice  is  closed,  crateriform 
when  it  remains  open.  The  hair  of  these  follicles  is  always  atrophic, 
and  often  invisible,  enclosed  and  rolled  up  in  the  horny  mass. 

This  lesion,  which  has  been  named  ichthyosis  pilaris,  is  chronic, 
difficult  to  reduce,  and  recurs  after  disappearance. 

The  treatment  is  of  the  type  called  exfoliative,  employed  in  ephe- 
lides,  etc.,  and  consists  in  the  application  of  sulphur,  resorcine  and 
salicylic  acid  with  the  object  of  causing  destruction  and  desquama- 
tion of  the  epidermis. 

Glycerine   of  starch 40  grammes  jj 

Precipitated  sulphur I  gramme  gr.  12 

Resorcine 4  grammes  gr.  48 

Salicylic  acid 4  grammes  gr.  48 

If  an  ointment  of  this  type  causes  much  smarting,  it  is  removed 
after  an  hour;  otherwise  it  is  left  on  for  several  hours,  or  during 
the  night,  and  removed  in  the  morning.  These  applications  are 
continued  till  exfoliation  takes  place,  and  renewed  as  often  as  neces- 
sary. If  there  is  much  irritation  it  may  be  relieved  by  oxide  of  zinc 
ointment. 

ICHTHYOSIS. 

True  ichthyosis  must  be  distinguished  from  keratosis  or  ichthyosis 
pilaris,  for  true  ichthyosis  is  not  accompanied  by  follicular  keratosis. 


THE    ARM. 


285 


It  consists  in  a  hyperkeratosis  of  the  surface,  more  marked  on  the 
extensor  surface,  and  less  in  the  folds  of  flexion,  which  are  nearly 
always  normal. 

It  consists   in   a   congenital   malformation,   which   is   sometimes 


Fisr.  133.     Keratosis   pilaris    of    the    arm.     (Brocq's   patient.     Photo,    by   Sottas.) 

hereditary  or  consanguineous.     It  is  incurable,  but  its  disfigurement 
and  inconvenience  may  be  diminished  by  suitable  treatment. 

The  skin  may  be  rendered  more  supple  by  means  of  oxide  of 
zinc  creams  and  glycerole  of  starch,  containing  i  per  cent  of  sali- 
cylic acid  or  resorcine.  It  is  important  to  warn  the  patient  that  the 
improvement  produced  will  not  lead  to  radical  cure. 


286  THE    ARM. 

SEBORRHOEIDS. 

The  term  seborrhoeids  covers  an  ill-defined  group  of  different  and 
analogous  types,  characterised  by  small,  disseminated  scurfy  lesions. 
Some  of  the  lesions  called  seborrhoeids  belong  to  well  defined  types ; 
pityriasis  simplex  (p.  519)  ;  the  scurfy  streptococcic  lesion  (p.  10)  ; 
pityriasis  rosea  (p.  521)  ;  psoriasis  (p.  525)  ;  others  are  less  defined, 
but  are  beginning  to  be  so,  such  as  parakeratosis  variegata  (p.  530), 
and  the  parapsoriasis  of  Brocq;  others  are  not  at  all  definite. 

The  root  of  the  limbs  is  a  common  situation  for  these  pityroid 
eruptions,  but  they  have  also  a  seat  of  election  by  which  they  can 
be  recognised.  Thus  pityriasis  simplex  affects  the  chest ;  pityriasis 
rosea  the  thorax ;  psoriasis  the  elbows  and  knees,  etc. 

These  localisations  confirm  the  diagnosis.  Benign  scurfy  lesions 
belonging  to  different  types,  usually  benefit  by  treatment  with  weak 
tar  ointments,  applied  at  night  and  washed  off  in  the  morning. 

Oil  of  Cade 4  grammes  5j  ss 

Oil  of  birch  .....  i  gramme  I 

Ichthyol I   gramme  ■  V  aa     gr.  24    , 

Resorcine i  gramme  |  I 

Lanoline 5  grammes  3ii 

Vaseline 15  grammes  5j 

PERMANENT    VESICANTS,     (i). 

The  old  "humoral"  ideas  often  led  to  the  application  of  a  vesi- 
cant in  front  of  the  arm,  in  which  suppuration  was  encouraged 
by  epispastic  ointments.  There  are  few  physicians,  nowadays, 
who  believe  in  the  efficacy  of  this  practice.  But  vesicants  are 
still  often  held  in  esteem  in  country  districts,  remote  from  medi- 
cal advice. 

A  useful  healing  application  for  these  sores  is  ointment  of 
sub-carbonate  of  iron,  i  in  40. 

PERMANENT    CICATRICES    OF  VESICANTS.^ 

The  permanent  vesicants  leave  an  indelible  cicatrix,  sometimes 
keloid    or    contractile,    which    may    cause    much    disfigurement. 

1  Translator's  Note. — The  Author  evidently  refers  to  the  use  of  issues 
and  setons. 


THE    ARM.  287 

These  may  be  improved  by  linear  scarifications  or  long  con- 
tinued plasters  of  oxide  of  zinc,  etc. 

On  these  cicatrices  either  a  fine  tuberculous  cheloid,  a  fungoid, 
or  ulcerated  lupus,  or  an  epithelioma  often  develops,  especially 
epithelioma  in  middle  age.  The  epitheliomas  implanted  on  a  ci- 
catrix are  generally  severe.  These  diverse  complications  ma}^  be 
treated  like  ordinary  cases :  The  epithelioma  by  excision  followed 
by  radiotherapy  of  the  cicatrix. 


THE    POSTERIOR    SURFACE    OF    THE    ELBOW. 

The  elbow  is  the  seat  of  election  of  many  dermatoses  and  one 
of  the  principal  localisations  of  several  others. 

As  on  the  knees,  ichthyosis  shows  its  maximum^  ^  ,    ,         . 
,                   .,        ,,              '  L  Ichthyosis     .    .    .   0.288 

degree  on  the  elbow J  ^ 

Psoriasis    also    forms    its    first    lesions    on    the^  .     . 

„                     .,      ,  K  Psoriasis   ....   0.289 

elbozv,  as  on  the  knee J  ^ 

Generalised  Xanthoma  shows   characteristic   l^-\^ 
sions  on  the  elbow  more  often  than  the  knee  .    .    .J  .    .    .  p.   oy 

The  tuberous  and  ulcerative  lesions  of   diabetica  Diabetic      xantho- 
xanthoma  have   the  same  predominance J      ma p.  290 

Scabies  often  occurs  round  the  elbozv  ^ 

co)nbination  of  genital,  gluteal,  digital,  and  axillary  iScahies       ....   p.  291 
localisations    of    the    affection J 

In   the  elboWj  as   on   the  knee,   there   is  a   siib-^ 
cutaneous  bursa,   the   inilamation   of  ivhich   raM.jr.?  I  Hygroma      .    .    .   p.  291 
hygroma J 

In  dealing  with  the   common  affections  of  the' 
region,  mention  may  be  made  of  palpation  of  the    Ulnar   nerve   in 

Ulnar  nerve,  and  of  the  results  which  it  furnishes  '     lepra p.  291 

in  Lepra 

The  semeiology   of  the  epitrochlear  gland  wilh 
be  studied J 


ICHTHYOSIS. 

The  extensor  surfaces  of  the  limbs  show  the  most  marked 
lesions  of  ichthyosis,  and  on  the  knees  and  elbows  they  are  still 
more  pronounced.  An  ichthyosis  which  is  only  distinct  on  the 
limbs  may  be  very  accentuated  on  the  elbows.  The  skin  is  cov- 
ered with  a  dry,  rough  thick  layer  of  keratosis,  always  segmented, 
in  the  folds  made  by  the  skin  of  the  elbow  in  extension.  These 
folds  may  be  red  and  eroded,  especially  during  the  cold  weather, 
in  persons  who  perform  manual  labour. 

The  treatment  consists  in  alkaline  baths  of  bicarbonate  of  soda 
and  the  application  of  resorcine  in  glycerine  of  starch  (i  per  cent). 


THE    POSTERIOR    SURFACE    OF    THE    ELBOW.  289 

PSORIASIS. 

In  the  clinical  picture  of  psoriasis,  the  squamous  patches  of  the 
elbow  take  an  important  place.  In  normal  cases  they  are  the  first 
to  appear  with  those  of  the  knee ;  and  they  may  remain  for  years 
without  patches  occurring  in  other  parts  of  the  body.  They  occur 
sometimes  in  the  form  of  a  single  large  squamous  placard,  thick- 
ened, grey  and  limited  by  a  slight  red  margin.  This  condition 
may  persist  for  years,  and  when  the  crust  falls,  it  is  renewed. 

If  this  thick  squame  is  scratched  it  comes  away  in  scales,  the 
deeper  ones  of  which  are  soft  and  white  like  soap.  If  the  squame 
is  removed  in  one  piece,  which  is  easy,  the  exposed  skin  is  covered 
with  characteristic  blood  points.  At  other  times  the  lesion  is  mul- 
tiple, consisting  of  small  elements  grouped  around  a  large  one; 
or  all  the  elements  may  be  small,  about  1-6  inch  in  diameter,  each 
covered  with  a  thick  adherent  squame  bordered  with  red.  The 
squame  and  adjacent  skin  have  the  same  characters  in  the  small 
as  in  the  larger  lesions.  Even  when  the  psoriasis  is  generalized, 
the  lesions  of  the  elbow  remain  the  same.  They  never  undergo 
spontaneous  resolution,  but  on  the  contrary,  persist  and  extend, 
always  towards  the  dorsal  surface  of  the  forearm. 

The  treatment  consists  first  in  cleansing  in  a  bath,  followed  by 
applications  of  the  following  ointments : — 

(i)   Yellow  oxide  of  mercurj'   .  1 

Resorcine r  aa     i  gramme  gr.  24 

Pyrogallic  acid ^ 

Oil  of  cade 10  grammes  5iv 

Lanoline 20  "  5i 

(2)  Chrysarabin      i  gramme  gr.  16 

Vaseline 3°  grammes  5i 

Solution  of  chrysarobin  in  chloroform  (10  per  cent)  may  also 
be  used,  allowed  to  dry  on  the  patches  and  covered  with  trau- 
maticin. 

The  treatment  takes  at  least  six  weeks  to  cause  disappearance 
of  the  lesions  and  should  be  continued  for  double  the  time  to  pre- 
vent recurrence. 

XANTHOMA. 

Xanthoma  of  the  elbow  resembles  that  of  the  eyelids,  but  the 
lesions  are  less  often  in  the  form  of  placards;  more  often  round 

19 


290 


THE    POSTERIOR    SURFACE    OF    THE    ELBOW. 

or  oblong  and  disseminated  (Fig. 
124). 

The  elements  consist  of  flat 
slightly  projecting  papules,  of  a 
yellow  or  rose  colour,  rather  soft  to 
the  touch  and  quite  painless.  They 
generally  occur  on  both  knees  and 
elbows  ;  sometimes  also  on  the  eye- 
lids. Similar  lesions  also  occur  on 
the  back  of  the  fingers,  or  in  their 
folds,  on  the  buttocks  and  some- 
times elsewhere. 

Sometimes  xanthoma  occurs  in  the 
form  of  a  large,  soft  and  mammil- 
lated  tumour,  which,  apart  from  the 
topographical  distribution  of  sim- 
ilar tumours,  resembles  molluscum 
(p.  627).  This  is  xanthoma  tuber- 
osum.    (Fig.  125.) 

In  these  two  forms  the  treatment 
is  the  same  as  for  xanthelasma  of 
the  eyelids;  viz.:  application  of  a 
fine  galvano-cautery,  which  causes 
the  tumours  to  disappear  rapidly 
without  leaving  scars.  No  internal 
treatment  gives  the  same  result. 


XANTHOMA  DIABETICORUM. 


Figr.  134.     Xanthoma      of      the 

elbow     (Besnier's  patient     St.  Diabctic    Xanthoma    differs    en- 

Louifa  Hosp.     Museum,   No.   6o4.) 

tirely  from  the  preceding  form. 
(For  the  connection  between  them  see  p.  632).  It  occurs  in  the 
form  of  tumours  of  different  sizes,  but  larger  than  that  of  a  rasp- 
berry. The  tumours  are  soft,  purple  and  sometimes  eroded  on  the 
surface,  or  even  ulcerated.  They  occur  on  the  whole  external  sur- 
face of  the  forearm,  although  more  numerous  around  the  elbow. 
The  evolution  is  connected  with  that  of  diabetes.  The  treatment  is 
that  for  diabetes,  with  local  applications  and  su1>carbonate  of  iron 
( I  in  40) . 


THE    POSTERIOR    SURFACE    OF   THE    ELBOW. 
SCABIES. 


291 


The  principal  localisations  of  scabies  are  the  penis,  the  front  of 
the  axilla,  the  elbows  and  wrists,  the  hands  and  fingers.  The  local- 
isation on  the  elbows  is  almost 
constant.  Scratch  marks,  caused 
by  the  nails,  are  the  first  lesions 
observed ;  afterwards  excoriated 
vesicles,  capped  by  a  thin  brown 
scab  of  dried  blood.  A  character- 
istic burrow  is  seldom  observed. 
These  lesions  are  situated  around 
the  elbow,  on  a  surface  about  2 
inches  in  diameter,  with  remark- 
able constancy.  They  are  very 
pruriginous,  especially  at  night. 
Scabies  avoids  the  head  and  neck 
entirely ;  an  important  negative 
sign.  Contagion  from  the  patient 
must  be  looked  for ;  from  mother 
to  child,  or  from  husband  to  wife, 
etc.  The  treatment  is  the  same  as 
on  p.  537. 

HYGROMA. 

Fisr.  125.     Xanthoma     tuberosum.        (Thi- 

wtlfn^  v''>^V-^'u^      ^*-    ^°"'^    "°^P-     Under    the    skin    of    the    elbow 

there  is  a  bursa,  which  sometimes 
becomes  inflamed  by  trauma;  suppurative  lesions  secondary  to 
scabies :  lymphangitis  or  abscess  of  the  neighbouring  parts,  etc. 
The  skin  is  red  and  hot,  with  all  the  signs  of  abscess.  Treatment 
consists  in  hot  fomentations  as  long  as  absorption  may  be  ex- 
pected ;  but  when  suppuration  is  distinct,  incision,  irrigation  and 
packing  with  aseptic  gauze  are  required. 


THE  ULNAR  NERVE  IN  LEPRA. 


The  ulnar  nerve  passes  in  a  groove  at  the  internal  and  posterior 
part  of  the  elbow  joint.  In  this  depression  it  may  be  felt  for  sev- 
eral inches  under  the  skin. 


292  THE    POSTERIOR    SURFACE    OF    THE    ELBOW. 

In  leprosy  the  nerve  becomes  hard,  moniliform  or  nodose,  and 
is  perceptible  for  an  extent  of  about  3  inches. 

This  is  an  important  lesion  in  leprosy  and  may  be  observed 
sometimes  at  the  first  period,  when  the  diagnosis  may  be  still 
uncertain  ;  especially  in  anaesthetic  leprosy,  in  which  lesions  of  the 
skin  may  be  scanty  and  less  characteristic  than  in  tubercular  lep- 
rosy (p.  655). 


THE  ANTERIOR  SURFACE  OF  THE  KNEE. 

The  knee  and  the  elbow  are  symmetrical  regions  with  similar 
dermatological  pathology.  This  region,  being  described  after 
that  of  the  elbow,  will  be  dealt  with  very  shortly.  The  corre- 
sponding paragraphs  of  the  elbow  may  be  referred  to  for  further 
details. 

Ichthyosis   of   the   knee   like   that   of   the   elbozu-\ 
often  presents  a  remarkable  degree  of  development^  yosis     .    .    .   p.  293 

Psoriasis   of   the   knee   as   of   the   elbow   shows^  .     . 

characteristic    lesions j  Psoriasis   ...       p.  293 

There   exists   on    the   knee   as   on    the   elbow   a-\ 
hygroma  of  the  prepatellar  bursa |Hygroma      .    .    .   p.  294 

And  a  localisation  of  xanthoma,  more  rare  and\ 
less  typical  than  on  the  elbow j- Xanthoma       ...  p.  294 


ICHTHYOSIS. 

In  very  marked  ichthyosis,  the  skin  of  the  knee  is  covered  with 
thick,  horny,  grey  placards,  very  adherent  and  fissured  in  all  direc- 
tions. Diagnosis  depends  on  the  universal  nature  of  the  lesion 
of  the  horny  layer,  which  is  abnormal  over  nearly  the  whole  body ; 
the  islands  existing  in  the  natural  folds ;  and  on  the  congenital 
nature  of  the  affection.     For  treatment  see  p.  518. 

PSORIASIS. 

Psoriasis  of  the  knee  is  generally  symmetrical,  and  the  knee  is 
usually  the  first  region  affected.  It  is  often  mistaken  by  the 
patient  for  a  callosity  and  taken  no  notice  of. 

It  may  always  be  distinguished  from  a  callosity,  caused  by 
kneeling  in  certain  occupations,  by  the  fact  that  the  callosity  is 
situated  in  front  of  the  tuberosity  of  the  tibia,  while  the  patch  of 
psoriasis  is  in  front  of  the  ligamentum  patellae. 

This  patch  may  be  large  and  single,  round  or  oval,  and  about 
an  inch  in  diameter;  or  it  may  consist  of  two  or  three  patches, 
which  unite  to  form  a  polycyclic  lesion ;  or  there  may  be  5  or  10 
spots  of  various  sizes,  but  all  similar  and  squamous,  with  ad- 


294  THE    ANTERIOR    SURFACE    OF    THE    KNEE. 

herent  laminated  scales,  the  debris  of  which  is  soapy,  white  and 
soft  to  the  touch.  On  removal  of  the  squame  the  epidermis  cov- 
ered with  blood  points  is  exposed. 

Diagnosis  is  only  difficult  when  the  lesions  are  scanty;  other- 
wise it  is  the  most  easy  of  all  dermatological  diagnoses.  As  a 
general  rule,  the  knee  does  not  present  eczematous  patches,  and 
the  so-called  chronic  eczemas  described  in  this  situation  are  cases 
of  psoriasis.  But  psoriasis  may  become  eczematised  and  mois: 
under  the  crust.     (For  treatment,  see  p.  525). 

HYGROMA. 

The  pre-patellar  bursa  may  become  inflamed  and  cause  a 
hygroma,  which  may  consist  of  serous  infiltration  and  end  in 
absorption  ;  or  may  suppurate  and  form  an  abscess.  The  intensity 
of  the  local  reaction  is  much  less  in  the  first  than  in  the  second. 
The  treatment  is  the  same  as  for  hygroma  of  the  elbow. 

XANTHOMA. 

Generalised  xanthoma  seldom  fails  to  present  lesions  on  the 
elbow,  but  its  localisation  on  the  knee  is  less  constant  and  less 
characteristic.  \Mien  the  lesions  occur  they  may  be  of  the  papu- 
lar, or  of  the  tuberous  variety  (p.  290). 


THE    LEG. 

The  surface  of  the  leg  is  one  of  the  cutaneous  regions  having 
the  most  special  pathology-.  This  peculiarity  is  due  to  its  depend- 
ent position  and  the  passive  congestion  and  varices  which  result 
therefrom. 

We  shall  first  study  the  pathology  of  the  region-) 
in  the  first  half  of  life,  zi'ith  the  streptococcic  til-  V  Ecthyma    ....    p.  296 
cerations  of  true  ecthyma J 

.    .    .   furuncle    and    furuncular    eruptions  .    .    .     Furuncle p.  297 

.    .    .   the   furunculous   ecthyma   of  staphylococ-^  Furunculous  ecthy- 
cic  origin J      ma p.  298 

.    .    .   the   rosette   eruptions   of  erythema   j«h//;-1  Erythema  multifor- 
forme J      me p.  299 

.    .    .   the  eruptions  of  purpura Purpura p.  299 

.    .    .  and  a  chronic  dermatitis  of  a  yelloii)  ochre\  Yelow       ochre    der- 
colour,  which  is  special  to  the  region J      matitis p.  300 

On  the  limbs,  all  dermatoses  may  assume  a  spe-} 

cial  aspect;  from  scabies,  which  is  nearly  always  I  Scabies p.  301 

pustular I 

.   .    .  to  the  round,  squamous  patches  of  psor-']  .    . 

.     .  r  Psoriasis p.  301 

tasts J  ^  "^ 

.    .    .   or  the  eruptions  of  lichen  planus  with  c.  \ 

^      .,          I  f Lichen  planus  ...  p.  302 

congestive    purple    colour J  ^  '^  -^ 

After  middle   age   ecsema   of   the   legs   becomes  1 

,  .        J       J-  /  [Eczema p.  302 

more  frequent  under  diverse  forms J  ^  "" 

.    .    .  And  venous  stasis,  and  varices  acquire  ol  Venous    stasis   var- 
prcponderating  influence  in  the  local  pathology  .    .J      ices P- 303 

On    a    varicose    skin    the    slightest    causes    may\ 

.          .             .■      i„„      ,;,■  (Traumatic  eczema  p.  304 

create  a   traumatic  dermatitis J  Fot 

Ulcer  of  the  leg,  zvhich  is  not  ahvays  varicose' 
is  a  common  and  characteristic  lesion.  It  also  has 
its  own  complications;  lymphangitis,  and  the 
special  elephantiasis  which  it  causes;  also  chronic 
oedema  with  pigmentation  and  papillomatous  hyper- 
trophy; lastly  progressive  cutaneous  sclerosis  and 
its  consequences 

Syphilis  has  also  its  particular  localisations  on 
the  leg.  Besides  the  flattened  tibia  of,heredo-syph- 
ilitics,  and  secondary  periostitis,  there  are  ter- 
tiary lesions;  diffuse  syphiloma  of  the  calf;  gum- 
mata  of  the  skin  and  syphilitic  ulcer 


-  Ulcer  of  the  leg  .  p.  304 


Syphilis p.  307 


^96  THE   LEG. 

IVe  shall  conclude  this  article  by  the  study  of 
rare  lesions  which  occur  in  the  leg  with  relative 
frequency.  For  instance  the  discrete  scattered 
lesions  of  lichen  corneus  with  atrophic  cicatricial 
evolution 


Lichen   corneus 

atrophicus  ....  p.  310 


.    .    .   also    symmetrical   alopecia    areata   ....     Alopecia    areata    .  p.  310 

.    .    .  supercicatricial  epithelioma Epithelioma  ....  p.  310 

.    .    .   tropical  elephantiasis,  or  filariosis  ....     Elephantiasis  .  .  .  p.  311 
.    .    .   and    Oriental    boil,    which    is    always    of\      .        ,   ,    ■ 

foreign  importation  in  our  country J  1    •  •  •  P- 3  - 

ECTHYMA. 

In  the  first  third  or  half  of  life,  physical  overwork,  standing, 
excessive  walking,  chlorosis,  apart  from  cardiac  or  renal  dis- 
eases, may  cause  oedema  of  the  legs,  which  increases  the  slightest 
inflammatory  lesion.  It  is  in  these  conditions  that  ecthyma,  furuncle, 
erythema  multiforme  and  purpura  generally  arise  in  young  persons 
or  adults.  In  adolescents  the  lesions  of  ecthyma  may  result  from 
accidental  inoculation;  but  they  only  develop  in  subjects  who  are 
overworked,  badly  nourished  or  cachectic. 

The  lesions  are  few  in  humber  and  disseminated.  They  are  ulcer- 
ated, with  sharp-cut  borders  and  a  sanious  base;  sometimes  closed 
by  a  papyraceous  scab  covering  a  seropurulent  liquid,  sometimes 
streaked  with  blood.  The  lesion  has  a  red  areola  up  to  the  point 
of  healing.  It  commences,  according  to  some,  by  a  pustule  which 
opens  and  becomes  excavated ;  according  to  others,  by  a  flat 
phlyctenule  which  undergoes  secondary  suppuration  and  ulceration.^ 

Varities  in  the  size  and  depth  of  the  lesions  have  only  verbal  im- 
portance ;  true  ulcerative  ecthyma,  at  whatever  age  it  appears, 
usually  gives  evidence  of  a  general  disorder;  such  as  tubercle,  dia- 
betes, and  enteritis  in  sucklings   (ecthyma  cachccticonun). 

Treatment  consists  in  rest,  baths  and  good  nourishment ;  and 
treatment  of  the  cause  when  this  is  recognised. 

Locally,  the  ulcerations  may  be  bathed  and  dressed  with  a  lotion 

of  2  parts  of  copper  sulphate  and  three  parts  of  zinc  sulphate  in 

500.    If  the  ulcers  remain  atonic,  sub-carbonate  of  iron  ointment  ( i 

in  40)  should  be  applied. 

1  This  difference  of  opinion  arises  from  an  error  in  terminology. 
Ecthyma  having  been  described  by  Willan  and  Bateman  under  the  name 
of  rupia,  a  word  which  has  fallen  into  disuse,  many  authors  describe  the 
ecthyma  of  Bateman,  which  is  furunculous  abscess,  as  the  beginning  of 
the  rupia  of  Bateman,  i.e.,  the  ulcerative  dermatitis  of  which  we  are 
speaking. 


THE   LEG. 


^ 


The 
patient 
weeks. 


prognosis  depends  entirely  on  the  general  condition  of  the 
;  the  healing-  of  the  ecthyma  itself  only  takes  two  or  three 


It  is  possible  that  ecthyma  may 
be  the  result  of  microbial  associa- 
tions. At  any  rate  cultures  of  the 
pus  from  the  ulcerations  always 
show  the  presence  of  streptococci. 
Until  more  information  is  obtained 
the  ecthyma  of  modern  writers,  or  the 
rupia  of  Bateman,  must  be  regarded 
as  a  common  impetigo  contagiosa, 
which  local  conditions  have  rendered 
ulcerative.  It  often  coexists,  more- 
over, with  impetigo  of  the  face  or 
body.  Ecthyma  is  easily  inocula- 
ble  by  vaccination.     (Vidal.) 

FURUNCULOSIS. 

When  furunculosis  is  generalised 
all  over  the  body,  the  furunculosis 
of  the  legs  is  only  a  simple  epiphe- 
nomenon  in  the  course  of  a  staphy- 
lococcic infection  of  the  whole  cu- 
taneous surface.  It  is  generally  re- 
lated to  diabetes,  phosphaturia  and 
other  cachectic  conditions. 

When  it  is  localised  on  the  legs 
it  is  due  to  the  same  local  and 
general  causes  as  ecthyma.  Each 
boil  commences  as  a  pustule,  the 
size  of  a  millet  seed,  situated  at  the 
orifice  of  a  hair  follicle.  The 
pustule  dries  up  and  is  removed  by 
scratching,  leaving  a  red  spot.  Three 
days  later  this  spot  is  acuminated, 
red  and  painful,  and  all  inflamma- 
tory phenomena  are  increased. 
Three  davs  later  still  the  boil  opens, 


Figr.  136.  Ecthyma  o  f  modern 
authors:  rupia  of  Bateman. 
(Lailler's  patient.  St.  Louis 
Hosp.    Museum,    No.    234.) 


298  THE   LEG. 

expels  a  green  sphacelic  core  and  the  inflammation  g-radually 
abates. 

In  furunculosis  of  the  legs,  out  of  lo  pustules,  5  abort,  3  become 
partially  f uruncular,  i  becomes  a  true  furuncle  and  1  develops  into  a 
peri-furuncular  abscess.  The  lesions  then  appear  polymorphous 
because  they  are  seen  in  diflferent  stages. 

This  is  one  of  the  chapters  of  staphylococcic  infection  of  the  skin, 
of  which  we  already  know  so  many  different  types,  resembling  each 
other  anatomically  and  bacteriologically,  but  differing  clinically. 

The  general  treatment  is  the  same  as  for  ecthyma.  Glycosuria 
should  be  treated  when  it  exists.  Phosphates  and  phosphoric  acid 
(10-40  drops  a  day)  often  give  good  results;  also  baths,  containing 
about  an  ounce  of  sulphate  of  zinc  to  60  gallons.  Good  effects  are 
obtained  by  galvano-puncture  of  each  pustule  as  soon  as  it  appears; 
or  in  the  absence  of  this,  a  drop  of  tincture  cf  iodine  may  be  applied 
after  epilation  of  the  infected  hair.  The  treatment  of  peri-furuncu- 
lar abscess  is  the  same  as  for  other  abscesses ;  incision  is  not  always 
necessary,  since  the  opening  of  the  furuncle  still  exists.  Antiseptics, 
of  any  kind,  should  be  used  in  very  weak  solutions  and  with  pru- 
dence (see  artificial  dermatitis,  p.  304). 

FURUNCULOUS    ECTHYMA. 

In  the  same  way  that  the  two  impetigos  were  confused  (pp.  7 
&  183)  without  clear  differentiation,  so  are  the  two  ecthymas  still 
confounded,  although  they  were  very  explicitly  differentiated  by 
Willan  and  Bateman  at  the  beginning  of  the  last  century.  We  have 
described  and  figured  actual  ecthyma,  the  former  rupia  of  Bateman, 
which  is  a  streptococcic  ulcer.  We  shall  now  say  a  few  words  con- 
cerning furunculous  ecthyma,  the  old  ecthyma  of  Willan.  It  is 
usually  observed  in  young  people  who  take  excessive  horse  exer- 
cise. It  commences  on  the  buttocks  as  an  ordinary  furunculosis, 
which  extends  to  the  whole  inner  surface  of  the  lower  limb. 

Each  furunculous  cavity  enlarges  by  a  circumferential  sphacelus 
formed  of  small,  distinct  cores,  side  by  side.  It  is  not  a  carbuncle, 
for  there  are  no  important  general  symptoms  and  the  furunculous 
crater  is  primarily  formed  by  a  single  core.  But  the  appearance  is 
that  of  a  cold  carbuncle  with  contiguous  cores,  developed  succes- 
sively. 

Treatment  consists  in  rest,  with  the  application  of  sub-carbonate 
of  iron  ointment  ( i  in  40) . 


THE   LEG.  29^ 

ERYTHEMA    MULTIFORME. 

Erythema  multiforme  has  three  seats  of  predilection ;  the  neck, 
wrists  and  legs,  with  predominance  of  lesions  around  the  ankles. 

The  characteristic  spots  appear  almost  simultaneously  and  the 
eruption  is  complete  in  one  or  two  days.  The  lesions  on  the  legs 
preserve  their  usual  characters ;  they  are  circular,  with  a  bistre 
coloured  centre,  a  red  border,  and  are  in  the  form  of  a  rosette.  The 
lesions  take  unusual  forms  in  this  region  more  than  others ;  they 
may  be  bullous,  or  extensively  erythematous,  each  efflorescence  hav- 
ing a  wide  purple  border ;  or  purpuric  with  punctiform  haemorrhages 
in  the  areola  of  each  element.  Polymorphous  erythema  generally 
follows  a  benign  infection,  after  3  to  8  days'  interval,  generally  an 
angina  or  naso-pharyngitis.  The  patient  is  often  conscious  of  infec- 
tion, which  manifests  itself  by  a  simple  febricula  without  any  signs 
sufficient  to  indicate  its  origin. 

The  patches  and  the  bullae,  when  they  exist,  appear  to  be  ami- 
crobial.  Even  the  blood  when  removed  at  the  period  of  erythema 
is  found  to  be  sterile  (Brocq).  The  most  probable  hypothesis  is 
that  erythema  multiforme  is  a  toxic  erythema.  According  to  some 
authors  erythema  nodosum  is  allied  to  erythema  multiforme,  but 
the  sub-cutaneous  painful  red  nodosities  of  erythema  nodosum  may 
develop  without  any  cutaneous  efflorescence.  This  is  probably  due 
to  sub-cutaneous  venour  thrombosis  (p.  605).  The  evolution  is 
the  same  as  in  erythema  multiforme. 

Treatment  consists  in  rest  in  bed  and  low  diet.  Bullae  should  be 
punctured,  but  not  decorticated.     The  prognosis  is  good. 

PURPURA. 

Purpura  may  occur  in  young  people  in  connection  with  some 
infection,  such  as  angina,  pneumonia,  influenza,  etc. ;  or  from  over- 
work in  young  soldiers,  vagabonds  and  alcoholics.  Sometimes  both 
causes  are  combined.  At  middle  age  the  same  causes  produce  it, 
but  when  it  recurs  it  generally  indicates  a  bad  state  of  circulation 
of  the  heart  or  kidneys  and  requires  a  guarded  prognosis. 

As  a  rule  purpura  is  limited  to  the  lower  half  of  the  body  and 
the  number  of  its  elements  increases  in  proportion  from  above 
downw-ards  to  the  ankle.     The  number,  size  and  tint  of  the  spots 


300  THE   LEG. 

also  increase  in  the  same  direction.  The  dimensions  may  vary 
from  that  of  a  grain  of  barley  to  patches  as  large  as  the  palm  of 
the  hand  (p.  597). 

Certain  forms  of  purpura  consist  of  patches  of  the  same  dimen- 
sions ;  others  vary  in  size ;  sometimes  all  the  patches  develop  and 
disappear  at  the  same  time;  at  other  times  the  eruption  is  formed 
gradually  and  disappears  in  the  same  way.  After  a  certain  size  the 
spots  assume,  after  a  few  days,  a  "contusiform"  tint  (Besnier). 
which  may  cause  them  to  be  mistaken  for  bruises.  All  degrees  occur 
between  an  almost  invisible  purpura  and  the  so-called  X'ehrloff's 
disease,  which  is  accompanied  by  haemorrhage  of  the  mucous  mem- 
branes, which  may  cause  death.  The  immediate  prognosis  of  pur- 
pura is  usually  benign ;  that  of  the  cause  of  variable  gravity.  Each 
case  must  be  judged  by  itself. 

Treatment  must  be  directed  against  the  source  of  infection  or 
intoxication.  The  nose  and  throat  should  be  disinfected.  Rest  in 
bed,  laxatives,  diuretics  and  chloride  of  calcium  (p.  597)  are  indi- 
cated; also  diminution  of  arterial  tension  by  high  frequency. 


YELLOW-OCHRE     DERMATITIS. 

This  term  is  applied  to  a  condition  which  is  common  in  varicose, 
diabetic  and  obese  subjects  at  about  the  50th  year.  The  leg  is  in  its 
lower  half  of  a  uniform  yellow  ochre  colour,  on  which  each  follicle 
appears  as  a  brown  point.  At  the  border  of  the  regional  lesion  are 
seen  isolated  elementary  lesions,  the  confluence  of  which  causes  the 
whole  appearance.  These  are  irregular,  reddish-brown  maculae, 
centred  by  a  brown  follicle.  When  the  hair  of  the  region  is  abund- 
ant, it  is  diminished.  There  are  no  functional  symptoms  except 
slight  pruritus. 

This  ill-defined  cutaneous  condition  appears  to  me  to  be  of  the 
same  nature  as  the  purpuras.  But  it  is  chronic,  and  when  estab- 
lished extends,  but  does  not  retrogress.  It  is  often  accompanied  by 
disorders  of  general  health,  especially  of  renal  origin,  such  as  inter- 
stitial nephritis. 

Local  treatment  consists  only  in  the  application  of  protective 
pastes.  The  general  condition  of  the  patient  must  be  carefully 
examined,  and  the  diet  regulated. 


THE    LEG.  301 

SCABIES. 

The  lesions  of  scabies  are  less  characteristic  on  the  legs  than  in 
other  regions,  such  as  the  axillae,  hands  and  penis.  Diagnosis  is 
not  usually  made  in  scabies  of  the  legs,  because  the  lesions  are 
nearly  always  complicated.  On  this  account  they  are  of  special 
interest. 

Very  few  burrows  are  found  and  the  lesions  consist  chiefly  of 
open  and  closed  pustules,  impetiginous  or  ecthymatous ;  lesions 
caused  by  scratching,  and  sometimes  eczematous  lesions  provoked 
by  all  causes  or  by  medicinal  applications.  Also  more  or  less  intense 
and  painful  lymphangitis  may  arise  from  an  ecthymatous  lesion. 
Finally,  red  and  painful  oedema  completes  the  picture. 

The  oedema  must  be  treated  by  rest  in  the  horizontal  position ; 
the  lymphangitis  by  moist  dressings,  and  the  ecthyma  by  lotions  of 
sulphates  (p.  lo).  After  this  the  scabies  can  be  treated  with  sul- 
phur in  the  usual  way  (p.  537). 


PSORIASIS. 


Psoriasis  is  rarely  limited  to  the  legs.  When  it  occurs  there  it 
has  the  usual  localisation  on  the  knees  and  elbows,  and  disseminated 
patches  are  found  on  the  body.  On  the  legs  psoriasis  may  occur 
in  all  forms,  from  small  spots  to  large  placards.  It  may  even  follow 
the  course  of  a  nerve,  such  as  the  external  popliteal,  but  this  is 
exceptional.  The  placards  are  slightly  raised  under  the  squames 
and  of  a  purple  colour.  Also  they  have  the  peculiarity  of  being 
intolerant  to  drugs,  and  are  reduced  with  difficulty,  the  patches  on 
the  legs  being  the  last  to  disappear  in  cases  of  general  psoriasis. 
Treatment  by  composite  ointments  is  the  best: — 


I  gramme 


3ss 


Oil  of  birch 

Ichthyol 

Resorcine 

Turpeth    mineral    .... 

O''  °f  '^^'^^ \  aa     15  grammes  \  aa     Si 

Lanoline J  J 


302 


THE    LEG. 


Sometimes  chrysarobin  (i  in  30)  gives  quicker  results.  Some 
cases  of  acute  psoriasis  require  5  or  6  weeks'  rest  in  bed  before  they 
are  cured. 


LICHEN    PLANUS. 

Lichen  planus  (lichen  ruber  of  Erasmus  Wilson)  is  even  more 
than  psoriasis  a  generalised  dermatosis  (p.  553).  It  never  occurs 
on  the  legs  alone,  but  usually  shows  there  its  special  characters.  As 
elsewhere,  the  lesions  form  flat,  shiny  papules,  intersected  by  fine 
white  lines  ;  one  large  papule  being  surrounded  by  a  group  of  smaller 
ones.  But  on  the  legs  these  lesions  may  become  coalescent,  of  a  deep 
lilac  colour  and  surrounded  by  a  purple  or  orange-red  areola.  Pru- 
ritus is  severe,  but  there  is  rarely  oedema  and  never  any  other  inflam- 
matory symptom. 

No  special  treatment  is  required,  and  there  is  no  satisfactory 
treatment  for  lichen  planus.  The  pruritus  may  be  alleviated  by 
sedative  ointments : — 


Resorcine   ...."]  1 

Tartaric  acid    .    .    .  Laa  40  centigrammes    L    aa     gr.  5 

Menthol |  J 

Glycerole  of  starch  40  grammes  5i 


ECZEMA. 

True  eczema  of  the  legs  is  rare.  It  may  occur  by  extension  from 
a  chronic  focus  of  eczema  in  the  popliteal  space  or  over  the  malleoli. 
Of  these  two  types  of  eczema  the  first,  like  the  popliteal  eczema  from 
which  it  proceeds,  is  more  common  in  the  adolescent.  It  is  con- 
comitant with  impetiginous  eczemas  of  the  folds  of  flexion  and  of 
the  face,  and  may  be  associated  with  hypoacidity  of  the  urine  and 
orthostatic  albuminuria.  Eczema  of  the  popliteal  space  is  nearly 
always  impetiginous  and  streptococcic  and  extends  onto  the  calf  in 
large  patches  caused  by  scratching.  Temporary  outbreaks  are  fol- 
lowed by  periods  of  remittence,  during  which  the  eczema  is  again 
limited  to  the  popliteal  space  or  disappears  altogether. 


THE    LEG.  303 

Treatment  consists  in  the  application  of  nitrate  of  silver  (i  in 
20  to  I  in  30),  alternated  with  zinc  paste.  When  remission  takes 
place  oil  of  cade  may  be  added  to  the  ointment. 

Eczema  which  extends  from  the  feet  to  the  legs,  differs  from  the 
preceding  type  in  occurring  at  adult  or  middle  age.  It  may  become 
exudative,  but  generally  begins  like  a  prurigo  by  groups  of  papules 
which  become  excoriated  by  scratching. 

In  acute  cases  accompanied  by  oedema  and  exudations  moist  dress- 
ings are  useful.  The  horizontal  position  with  the  feet  raised  is  not 
essential.  In  the  intervals  of  the  acute  attacks  nitrate  of  silver  ( i  in 
30  to  I  in  5)  should  be  applied  to  the  last  lesions. 

This  form  of  eczema  may  coincide,  like  many  others,  with  malnu- 
trition and  emaciation  and  only  subside  after  improvement  in  diet 
and  return  to  normal  weight. 


VENOUS     STASIS.       VARIX.       VARICOSE     PHLEBITIS. 

Owing  to  the  dependent  position  and  almost  continual  work,  the 
leg  is  exposed  more  than  any  other  region  of  the  body  to  passive 
congestion,  venous  stasis,  varicose  dilatations  and  the  troubles  arising 
therefrom.  This  predisposition  is  increased  by  all  inflammatory  con- 
ditions and  vice  versa,  causing  a  vicious  circle  which  may  exhibit 
nearly  all  the  cutaneous  affections  of  the  limb.  Varices  are  not  only 
the  mechanical  result  of  venous  stasis,  but  result  from  many  causes, 
some  obscure  and  hereditary,  others  due  to  a  chronic  inflammatory 
condition  added  to  mechanical  congestion.  At  intervals  this  inflam- 
matory state  increases  and  becomes  varicose  phlebitis,  usually  lim- 
ited to  a  secondary  venous  branch  and  characterised  by  all  the  inflam- 
matory phenomena:  "color,  rubor,  tumor,  dolor." 

Varicose  phlebitis  thus  occurs  in  crises  at  different  intervals  which 
end  in  absorption  and  disappearance  of  the  inflammatory  signs,  or 
more  often  bv  painless  induration.  These  changes  may  occur  at  any 
age  in  the  adult,  but  are  more  frequent  in  middle  age.  They  are 
predisposed  to  by  obesity,  cardiac  affections,  and  pregnancy. 

Although  these  affections  do  not  properly  belong  to  dermatology, 
they  underlie  such  a  large  number  of  local  dermatoses  and  affect 
their  prognosis  so  much,  that  the  dermatologist  should  be  well 
acquainted  with  them  and  should  measure  their  importance  in  each 
case. 


304  THE    LEG. 

The  treatment  is  very  limited.  There  is  no  treatment  for  the 
general  condition  which  causes  varicosity  and  no  internal  treatment 
for  varix.  The  want  of  tone  in  the  walls  of  the  veins  and  the  result- 
ing stasis  and  ccdema  may  be  improved  by  elastic  stockings,  the 
recumbent  position,  etc.,  and  when  necessary  by  local  antiphlogistics 
and  moist  dressings  during  the  attacks  of  phlebitis. 

A  great  number  of  drugs  have  been  used  empirically  in  varix, 
such  as  belladonna,  hammamelis,  etc.,  but  they  are  of  doubtful  value. 


ARTIFICIAL    DERMATITIS. 

Most  eczemas  of  the  legs  are  caused  by  some  form  of  traumatism ; 
these  are  artificial  dermatites.  A  dermatitis  may  occur  around  the 
injured  spot  and  often  results  from  the  application  of  drugs,  such  as 
arnica,  carbolic  acid,  salol,  iodoform,  turpentine,  etc.  These  appli- 
cations are  often  responsible  for  artficial  dermatitis  of  the  legs, 
which  are  true  eczemas,  provoked.  They  form  red,  more  or  less 
finely  vesicular  and  exudative  epidermatites,  often  infected  and 
impetiginous  (pustules  and  boils),  with  a  lilac  coloured  fibrinous 
layer  under  an  amber  coloured  scab.  They  are  always  accompanied 
by  inflammatory  oedema  and  venous  stasis,  which  hinder  healing, 
especially  when  physical  exercise  causes  them  to  persist  and  increase. 

Treatment  consists  in  removal  of  the  cause;  rest  in  bed  with  the 
legs  elevated ;  moist  dressings  with  boiled  water  till  inflammation 
has  subsided ;  and  afterwards  oxide  of  zinc  ointment. 


ULCER   OF   THE   LEG. 

Ulcer  of  the  leg  is  one  of  the  commonest  and  most  distressing  dis- 
eases affecting  the  poorer  classes.  It  results  from  many  morbid 
conditions  mentioned  above,  and  also  gives  rise  to  others.  In  the 
pathogeny  of  ulcer  of  the  leg  it  is  necessary  to  understand  all 
the  causes  in  the  midst  of  which  it  is  produced.  The  thinness  of 
the  skin  in  front  of  the  tibia,  the  resistance  of  the  subjacent  bone, 
the  passive  congestion,  varices  and  chronic  oedema,  which  diminish 
the  nutrition  of  the  subcutaneous  tissues,  are  all  predisposing  causes  : 
and  as  all  inflammation  aggravates  these  unfavourable  conditions,  it 
often  happens  that  a  sore  of  the  leg  fails  to  heal. 


i 


THE    LEG. 


305 


Ulcer  of  the  leg  may  follow  an  injury,  a  boil  or  ecthyma,  a 
mosquito  bite,  or  even  a  simple  excoriation  in  prurigo.  The  idea 
that  a  wound  of  a  vein  is  incurable  is  a  popular  expression  of  this 
clinical     truth,    that    varicose    legs    are    predisposed    to    atonic 

ulcerations.  The  immediate 
cause  of  the  ulcer  may  vary ;  it 
may  be  syphilitic,  or  a  chronic 
streptococcic  ulcer,  or  an  ecthy- 
ma ;  but  the  predisposing  causes 
are  always  the  same. 

The  primary  wound  becomes 
congested  and  its  temperature 
exceeds  that  at  which  cellular 
exchanges  and  multiplications 
are  best  performed.  This  pre- 
sents cicatrisation ;  the  edges  of 
the  wound  swell  up  and  dis 
charge  or  granulate  ineffective- 
ly ;  the  wound  becomes  infected 
and  an  epidermic  sphacelus  is 
produced  around  the  primary 
ulceration ;  this  enlarges  and 
the  edges  become  thickened 
sloping  and  of  lardaceous  con- 
sistence. During  this  time  the 
hypodermis  reacts  and  becomes 
slowly  fibrous,  and  the  base  of 
the  ulcer  is  formed  of  cicatricial 
tissue,  without  epidermis.  The 
ulcer  thus  remains  atonic,  or 
enlarges,   so  slowly  that  a  la- 

Fig.  127.     Simple  i:lcer  of  the  leg.  simulating  bouriug     man     takcS  UO     nOtlCC 
an     ulcerated     syphilitic     gumma.        (Bes-                     ^ 

nier's   patient.      St.    Louis   Hosp.      Museum,  pf    it  I    the    fUHCtlOnal  SVmOtOmS 

No.    287.)                                                                                            '         ^  J       f 

being  slight. 
The  skin  round  the  ulcer  becomes  hard  and  thickened,  pigmented 
and  purple,  and  the  surface  is  slightly  scaly.  This  change  may: 
extend  over  four  inches  or  more  beyond  the  ulcer.  The  skin  grad- 
ually becomes  more  vulnerable  to  infection  and  trauma.  Other 
ulcers  form  around  the  first  and  coalesce  with  it.  In  this  way, 
20 


3o6 


THE    LEG. 


especially  in  the  working  classes,  ulcerations  of  4  inches  or  more 
in  extent  are  formed,  which  render  the  leg  permanently  unser- 
viceable. 

The  duration  of  these  ulcers  is  unlimited;  they  enlarge  till  the 
uselessness  of  the  limb  obliges  the  patient  to  lay  up.     The  ulcer 

heals  partly  under 
treatment  and  then 
breaks  down  again. 
Moreover,  it  may  give 
rise  to  complications. 
Lymphangitis  may 
suddenly  arise  with 
local  and  general 
symptoms  of  erysipe- 
las, due  to  streptococ- 
cic infection.  This 
develops  like  erysipe- 
las and  undergoes 
spontaneous  resolu- 
tion ;  but  it  may  recur, 
and  each  time  leaves 
the  chronic  oedema  of 
the  parts  more  intract- 
able. In  this  way  is 
constituted  elephanti- 
asis nostras  as  the  re- 
sult of  recurrent  "ele- 
phantiasic  outbreaks," 
as  was  formerly  de- 
scribed. 

The  chronic  derma- 
titis gradually  increas- 
es and  the  surface  of 
the  skin  assumes  the 
most  unusual  appear- 
ance.    Xot  only  is  it 
thickened  but  the  surface  is  lobulated  or  villous,  bristling  with  conical 
papillomatous  projections.     In  some  places  the  dermatitis  is  exu- 
dative and  crusted,  forming  "varicose  eczema";  at  others  the  skin 


Figr.  128.     Varicose  ulcer  of  leg. 

(A.     Fournier's    patient.      St.     Louis    Hosp. 

Museum,    No.    1485.) 


THE    LEG.  307 

is  contracted  by  fibrous  bands,  longitudinal,  oblique,  stellate  or  cir- 
cular; the  cicatrices  of  former  ulcers  more  or  less  healed.  The  leg 
then  loses  its  shape  and  may  be  from  20  to  25  inches  in  girth,  with 
holes  and  protuberances,  and  sometimes  annular  cicatricial  con- 
tractions where  it  is  narrower  than  the  normal  leg.  Such  a  condi- 
tion may  lead  to  amputation,  and  in  patients  who  are  not  amputated 
the  limb  is  often  less  serviceable  than  a  wooden  one.  The  ulcers 
during  their  period  of  increase  and  sphacelation  exhale  a  putrid 
odour,  and  are  occasionally  infested  with  worms. 

Treatment.  The  first  treatment  in  ulcer  of  the  leg,  and  its  result- 
ing chronic  dermatitis,  is  to  put  the  patient  to  bed.  After  a  week's 
rest  and  a  daily  bath  the  lesions  are  transformed;  the  oedema,  red- 
ness, and  varices  have  diminished  by  half;  the  edges  of  the  ulcer 
are  flatter ;  the  ulcer  is  not  bordered  with  points  of  sphacelation,  but 
is  nearly  dry  and  free  from  offensive  odour.  Dressings  of  boiled 
water  diminish  the  circumferential  patches  of  exudative  dermatitis, 
which  contract  and  become  covered  with  epidermis.  The  ulcer 
itself  is  dressed  with  ointment  of  sub-carbonate  of  iron  (i  in  40). 
After  I  to  4  weeks  the  small  ulcers  are  healed,  the  middle  sized  ones 
diminished  by  half,  and  the  large  ones  clean  and  improving.  In 
order  to  hasten  the  epidermisation,  the  edges  of  the  ulcer  may  be 
scarified  in  radiating  or  circular  lines ;  the  hypertrophic  dermatitis 
and  villosities  also  benefit  by  scarification  every  week.  After  several 
interventions  of  this  kind  the  skin  becomes  level  and  resumes  as  far 
as  possible  its  normal  characters.  There  still  remain  fibrous  inex- 
tensible  bands  and  the  bases  of  the  large  ulcers  where  the  skin  is 
absent.  These  may  be  treated  by  Tiersch's  grafts,  after  freeing  the 
edges  and  scraping.  By  these  methods  the  functions  of  the  lower 
limb  are  restored  as  much  as  is  possible.  Afterwards,  especially 
when  the  patient  resumes  work,  frequent  baths  should  be  taken  and 
the  cicatrices  should  be  protected  by  a  layer  of  non-absorbent  wool 
and  the  leg  kept  in  an  elastic  stocking. 

This  treatment  renders  serviceable  a  limb  which  it  is  impossible  to 
restore  to  its  normal  state  when  such  irreparable  lesions  are  once 
formed. 

SYPHILIS. 

Syphilis  may  manifest  itself  in  the  leg  by  very  different  lesions, 
(i)    The    flattened   tibia,   concave   internally,   called    "sabre   blade 


3o8 


THE    LEG. 


tibia"  constitutes  one  of  the  most  certain  signs  of  hereditary  syphiHs. 

(2)  Secondary  syphiUtic  periostitis  which  occurs  with  the  roseola 

is  often  accompanied  by  severe  local  pains  which  may  cause  errors  in 

diagnosis.  Palpation  reveals  a  diffuse, 
hard  and  painful  thickening  of  the  mid- 
dle of  the  internal  surface  of  the  tibia, 
usually  extending  for  4  or  5  inches. 
This  slight  deformity  results  from  a 
sub-periosteal  lesion  which  persists 
permanently,  after  the  pain  has  disap- 
peared in  5  or  6  weeks. 

Tertiary  syphilis  may  also  give  rise 
to  special  lesions  in  this  region. 

(i)  Diffuse  syphiloma  of  the  calf 
occurs  usually  as  an  ill-defined  red  tu- 
mour, as  large  as  the  palm  of  the  hand, 
which  soon  becomes  fixed  to  the  skin 
and  to  the  muscle.  The  hardness  in- 
creases progressively  and  the  swelling 
is  not  accompanied  by  functional  symp- 
toms proportional  to  its  size.  This  is 
diflfuse  syphiloma  of  the  calf.  Diag- 
nosis has  to  be  made  from  abscess  and 
sarcoma.  Mixed  treatment  causes  soft- 
ening of  the  mass  in  8  or  10  days  and 
disappearance  in  a  month. 

(2)  This  type  of  diffuse  syphiloma 
indicates  the  form  which  nearly  all  ter- 
tiary lesions  assume  in  the  leg.  They 
are  nearly  always  hypodermic  gum- 
matous processes,  some  of  large  size, 
deep  and  diffuse  like  the  above;  others 
thin  and  in  sheets,  ending  rapidly  in  syphilitic  ulcer,  which  is  formed 
by  small,  disseminated,  irregularly  ulcerated  gummata. 

These  processes  may  occur  at  all  parts  of  the  leg,  more  often  about 
the  middle  and  on  the  antero-lateral  surface.  The  first  stage  is 
rarely  seen.  This  consists  in  a  more  or  less  coherent  crop  of  small 
intra-cutaneous  tumours,  the  size  of  a  pea,  almost  painless,  orange- 
red  or  violet  in  colour,  which  become  eroded  singly  or  together, 
without  fluctuation.     Their  centre  is  necrotic  and  is  infected  much 


Fig:.  12».  Syphilitic  Gumma 
of  the  calf.  (Le  Dentu's 
patient.  St.  Louis  Hosp. 
Museum,    No.    662.) 


THE  LEG.  309 

less  than  the  points  of  sphacelation  in  ulcer  of  the  leg.  The  cores 
are  eliminated  and  leave  an  irregular  sore  with  a  sinuous  and  poly- 
cyclic  margin.  Inflammatory  phenomena  in  the  surrounding  parts 
are  less  marked  than  in  ordinary  ulcer  of  the  leg. 

The  syphilitic  ulcer  is  serpiginous  and  may  partly  heal  without 
treatment.  It  is  liable  to  recur  and  is  often  seen  by  the  side  of 
cicatrices  of  former  lesions.  The  olive  brown  cicatrix  encircled  with 
purple  is  not  so  characteristic  as  many  authors  maintain;  but  a 
cicatrix,  without  being  pathognomonic  may  support  the  suspicion 
of  former  syphilitic  ulcer,  that  of  simple  ulcer  of  the  leg  being 
irregular  and  generally  surrounded  by  much  more  marked  chronic 
dermatitis. 

(3)  Instead  of  a  crop  of  gummata,  or  a  diffuse  syphiloma,  a  single 
gumma  may  develop  on  the  leg,  the  size  of  a  walnut,  with  sub-acute 
inflammatory  symptoms  and  almost  without  pain.  The  swelling 
points  and  gives  way  in  the  form  of  a  crescent,  revealing  a  yellow 
core,  the  hollow  of  which  deepens  slowly.  The  cavity  may  be  as 
large  as  a  marble,  and  the  ulceration  remains  atonic  till  diagnosis  is 
made  and  treatment  commenced. 

(4)  Lastly,  there  exists  a  tertiary  serpiginous  syphilide,  very 
superficial,  which  forms  almost  ornamental  figures,  by  a  red  border 
covered  with  a  thin  and  irregular  crust.  This  crust  is  adherent  and, 
when  removed  without  much  force,  raises  all  the  subjacent  epider- 
mis and  the  entire  thickness  of  the  skin,  exposing  a  small,  irregular 
hole,  from  which  exudes  a  drop  of  blood. 

All  these  lesions  are  amenable  to  active  anti-syphilitic  treatment. 
To  verify  an  uncertain  diagnosis  energetic  treatment  may  be  insti- 
tuted, by  two  injections  of  biniodide  of  mercury,  or  one  of  grey  oil  in 
a  week;  or  i^^  drachms  of  grey  ointment  by  inunction.  Pills  of 
protoiodide  or  sublimate  should  only  be  used  for  this  purpose  in  the 
absence  of  other  methods. 

In  spite  of  the  relative  discredit  into  which  the  iodides  have 
recently  fallen,  they  preserve  their  value  in  the  treatment  of  gum- 
matous manifestations,  and  may  be  prescribed  regularly  in  doses 
of  15  to  30  grains  daily.  The  effect  takes  place  in  one  or  two  weeks, 
but  the  cure  may  be  slow  or  incomplete  if  the  loss  of  substance  has 
been  considerable.  Local  treatment  may  be  the  same  as  for  simple 
ulcer  of  the  leg.  The  emplastrum  of  Vigo  may  be  used  for  small 
ulcers,  but  is  a  dirty  method. 


3to  THE   LEG. 

LICHEN     PLANUS     CORNEUS     ATROPHICUS. 

This  affection  is  more  common  on  the  legs  and  scalp  than  else- 
where. It  is  a  rare  dermatological  type,  the  nature  of  which  is  not 
exactly  determined.  It  is  characterised  by  a  few  patches,  generally 
elongated,  from  ^  to  i  inch  in  diameter.  The  lesion  resembles" 
a  nasvus.  It  has  three  aspects;  when  complete,  it  is  raised  and  cov- 
ered with  a  hard  adherent  corn,  analogous  in  consistence  to  that  of 
warty  nsevi  and  papillomata,  but  is  not  divided  into  segments  like 
the  horny  tissue  of  warts.  Under  the  crust  the  lesion  is  raised,  dry, 
hard,  and  does  not  bleed.  Lastly  the  lesion  often  shows  at  one  end, 
the  terminal  stage,  a  smooth  slightly  depressed  cicatricial  point. 

The  treatment  consists  in  destruction  by  caustic  plasters  or  by 
the  galvano-cautery. 

ALOPECIA     AREATA. 

Symmetrical  alopecia  areata  of  the  legs  is  not  very  rare  in  cases 
of  alopecia  with  a  tendency  to  become  generalised.  It  is  situated  on 
the  middle  third,  and  on  the  external  surface.  It  is  especially 
observed  in  subjects  in  whom  the  general  condition  is  at  fault:  ner- 
vous asthenia,  marasmus,  choreiform  movements,  hereditary  syphilis, 
tuberculous  cachexia,  etc. 

It  requires  no  local  treatment,  but  a  stimulating  alcoholic  lotion 
may  be  prescribed  for  moral  effect. 


SUPERCICATRICIAL    EPITHELIOMA. 

On  the  leg,  as  in  other  regions,  epithelioma  may  develop  on 
cicatrices  and  it  presents  no  peculiar  features  in  this  situation.  On 
the  cicatrix  of  a  wound,  a  burn  or  a  chronic  sore,  develops  a  mam- 
millated  bud  covered  by  the  thin  and  smooth  epidermis  of  the  cica- 
trix. This  bud  becomes  raised,  rounded  and  sometimes  peduncu- 
lated ;  sometimes  flat  and  circular.  Treatment  consists  in  surgical 
removal  followed  by  applications  of  the  X-rays  to  the  cicatrix 
(about  25  units  H  in  5  or  6  sittings ;  tint  B  of  the  radiometer  X. 


THE    LEG. 


311 


TROPICAL     ELEPHANTIASIS.      FILARIOSIS. 

Equatorial  countries  present  cases  of  elephantiasis  by  repeated 
erysipelas  similar  to  ours ;  but  they  have  besides  a  special  elephanti- 
asis, due  to  the  pullulation  of  Hlaria  sanguinis  hominis  in  the  blood, 
the  embryo  being-  transported  by  a  mosquito,  the  culex  mosquito, 
and  transmitted  to  man  by  the  bite. 


Fig.  130.     Filarial   elephantiasis.     (Jeanselme's    patient.     Photo,    by    Noirfi.) 


It  consists  in  a  chronic  oedema,  often  accompanied  by  lymphatic 
varices  visible  on  the  surface ;  a  kind  of  pachydermia  without  hyper- 
chromia. Generally  the  two  lower  limbs  are  affected  equally,  and 
sometimes  the  genital  organs.  It  is  a  chronic  disease  with  acute 
exacerbations    resembling    attacks    of    lymphangitis.     During    the 


312  THE    LEG. 

period  of  exacerbation,  microscopic  examination  of  the  blood  during 
the  night,  shows  the  existence  of  the  filaria,  a  mobile  serpentine 
larva  about  0.8  fi  in  length.  The  affection  is  not,  strictly  speaking,  a 
dermatosis  and  is  rare  in  our  country. 


ORIENTAL    BOIL. 

This  generally  occupies  the  lower  third  of  the  leg  and  consists 
of  one,  two  or  three  similar  ulcerative  lesions,  the  type  of  which 
will  be  described  with  its  most  common  localisation  on  the  back  of 
the  hand  (p.  348).  It  occurs  in  Persia,  Asia  Minor,  Turkestan  and 
the  Far  East. 


THE  FOLD  OF  THE  HAM  AND  THE  FOLD  OF  THE 

ELBOW. 

The  dermatological  pathology  of  the  folds  of  the  ham  and  elbow 
are  so  similar  that  they  may  be  considered  in  one  chapter. 


-  Prurigo  of  Hebra  p.  313 

Impetiginous  ecze- 
ma of  adoles- 
cents    P-3I4 

Lichenisation    Ec- 
zematisation   .    .   p.  315 


The  prurigo  of  Hebra  occurs  frequently  in  these 
regions  with  its  pruritic  papular  eruption  and  ec 
zematisation 

The  impetiginous  eczema  of  adolescents,  which' 
is  usually  accompanied  by  urinary  hypoacidity  and 
transitory  albuminuria,  is  often  exclusively  localised 
on  the  folds  of  the  elbows  and  knees 

/  shall  say  a  few  words  regarding  the  thickening' 
of  the  skin,  known  as  lichenisation,  and  the  exuda- 
tive phases  known  as  eczematisation,  which  are 
common  in  the  evolution  of  many  dry  lesions  .    .    . 

Typical  psoriasis  avoids  the  folds  of  Hexion,  but'\ 
steatoid    psoriasis    {nummular   seborrhoeic    ^c^ewo  LSteatoid   Psoriasis  p.  317 
of  Unna)  does  not J 

/   shall    next    deal   with    ichthyosis,   which    pre-^  ,  ,   ,        . 

^i      J-  I J       /  ^     •        •  ^     X  \  Ichthyosis   ...    .p.  318 

serves  the  folds  of  nexton  intact J 

.    .    .   and  zvith  intertrigo  and  parasitic  eruptions ■\  -r  .     .  ■        p 

of  the  folds  of  flexion;  although  they  are  less  com-  [     .    „        .  _ 

.  '    ,        '  ,     ,,         .1         ;       ;  ic  Eruptions  ...  p.  318 

mon  in  the  nam  and  elbow  than  elsewhere  ...    .J  *^  *^  ^ 

.  ]  Semiology  of  pop- 
/  shall  conclude  zvith  a  few  words  on  the  semet- 1      ijtgal     and     eoi- 
ology  of  the  glands  of  these  two  regions [      trochlear  glands  p.  318 

Epitrochlear  gland 
in  digital  chan- 
cre     p.  319 

PRURIGO    OF    HEBRA.       LICHEN.       PRURIGO    IN    GENERAL. 


.    .    .  especially  the  epitrochlear  gland  of  syph-' 
ilitic  chancre  of  the  fingers 


The  prurigo  of  Hebra  is  a  dermatosis  characterised  by  generalised 
pruritus  and  accompanied  by  a  more  or  less  marked  eruption  of 
small  conical  elevations,  papular  in  appearance,  in  reality  hollowed 
by  a  small  central  vesicle,  which  is  excoriated  by  scratching  (papulo- 
vesicle) . 

This  eruption  soon  becomes  polymorphous,  because  the  lesions 
have  pigmentary  traces ;  the  pruritus  slowly  causes  diffuse  licheni- 


314  FOLDS    OF    HAM    AND    ELBOW. 

sation  of  the  skin;  and  the  young  papulo-vesicles  are  mixed  with 
others,  which  have  been  excoriated  and  scabbed  over. 

This  affection,  which  was  formerly,  and  not  without  cHnical  rea- 
sons, classed  among  the  "benign  scrofulides"  is  by  some  considered 
as  an  autonomous  disease ;  by  others  as  one  of  the  forms  of  chronic 
lichen-urticarias,  which  occur  at  all  ages;  usually  at  the  extreme 
ages,  in  the  child  as  chronic  urticaria,  and  in  the  aged  as  senile 
pruritus  without  lesions.  Eczematisation  of  these  lesions  is  frequent, 
but  appears  to  be  an  accidental  addition  to  the  disease  itself. 
Lichenisation  may  follow  eczematisation,  or  may  occur  without  it. 

The  internal  treatment  of  prurigos  is  theoretical  and  differs 
according  to  opinion.  Local  treatment  is  symptomatic  and  espe- 
cially anti-pruriginous.  Protective  ointments  and  pastes  which  pre- 
vent direct  contact  of  the  air  with  the  skin  appear  to  be  the  best. 
In  severe  cases  a  good  plan  is  to  envelope  the  part  in  bandages 
impregnated  with  cod-liver  oil.  The  ointments  should  contain  a 
third  part  of  oil  of  cade. 

Prurigo  of  Hehra  generally  improves  witli  age,  and  is  cured  8 
times  out  of  lo;  but  the  disease  is  paroxysmal,  and  isolated  attacks 
may  occur  long  after  apparent  cure. 


IMPETIGINOUS  ECZEMA  OF  ADOLESCENTS. 

Impetiginous  eczema  of  adolescents,  which  we  have  studied  on  the 
face,  has  a  marked  predilection  for  the  folds  of  the  elbows  and 
knees.  The  eruption  often  arises  in  all  points  at  the  same  time,  in 
the  form  of  small  soft  red  projections,  which  become  vesicular. 
Others  occur  between  these,  and  serous  exudation  is  established  over 
a  lozenge-shaped  surface,  of  which  the  fold  of  flexion  represents 
the  small  diameter.  The  exuded  liquid  forms  yellow,  fatty,  fissured 
crusts.  The  eroded  surface  is  often  infected  with  streptococci  and 
becomes  impetiginous.  This  eruption  is  more  common  in  the  ham 
than  in  the  fold  of  the  elbow  and  is  very  tenacious  and  troublesome. 

Analysis  of  the  urine  often  shows  hypoacidity  and  temporary  albu- 
minuria in  these  cases,  which  were  formerly  classed  among  the 
eczemas  of  scrofula.  The  clinical  relationship  which  underlies  this 
old  classification  remains  true  and  indicates  the  general  treatment. 

The  local  treatment  should  always  be  active  in  these  regions. 
Repeated  applications  of  nitrate  of  silver  (i  in  20  to  i  in  10)  are 


FOLDS   OF   HAiM   AND    ELBOW, 


315 


necessary.  If  these  are  irritating  or  badly  tolerated  a  moist  dressing 
may  be  applied  afterwards.  Usually  they  are  well  tolerated  if  the 
parts  are  covered  with  zinc  paste.  When  the  first  irritation  has 
subsided  the  best  local  treatment  consists  in  the  application  of  weak 
oil  of  cade  ointment: — 


Oxide    of    zinc \ 

Oil  of  cade J     ^^ 

Ichthyol \ 

Oil  of  birch J    ^^ 

Lanoline 1 

Vaseline J     ^^ 


5  grammes 

} 

Biiss 

I  gramme 

} 

gr.  30 

:5  grammes 

I 

5ss 

ECZEMATIiJATION.       LICHENISATION. 

Any  chronic  irritation  of  the   fold  of  the  elbow  and  ham  may 
lead  to  progressive  thickening  of  the  skin  of  the  region,  as  in  liche- 


Fig.  131.      Associateil   lichcnisatinn  nn<l   crzptnatlsatloil. 
(Brocq's   patient.     Photo,    by    Sottas.) 

noid  transformation  in  the  forearm;  and  this  may  occur  when  the 
lesions  are  always  dry  as  in  prurigo,  or  when  there  has  been  eczema 
and  exudation. 

This  process  of  lichenisation,  which  represents  a  particular  reac- 
tion of  the  skin  to  certain  chronic  irritations,  must  be  considered  not 
as  a  disease  in  itself  but  as  a  complication  of  several. 


3i6  FOLDS    OF    HAM    AND    ELBOW. 

Also,  ecsematisation,  which  is  the  production  of  local  or  diffuse 
serous  suffusion,  the  former  forming  vesicles,  the  latter  creating 
more  or  less  superficial  exudation,  may  also  be  considered  as  a  sim- 
ple cutaneous  reaction.  Hence  the  first  in  date  of  the  phenomena 
which  are  accompanied  later  by  eczematisation  or  lichenisation, 
remains  doubtful.     An  idiopathic  pruritus  without  lesions,  giving 


Fig.  138.     Same   condition   as   Fig.    131.       (Brocq's   patient.     Photo,   by   Sottas.) 

rise  to  lesions  by  scratching  has  been  suggested  as  the  origin  of 
most  cases,  but  this  hypothesis  is  very  difficult  to  prove.  All  biop- 
sies of  a  pruriginous  skin  show  histological  vesicular  lesions,  invisi- 
ble to  the  naked  eye,  which  might,  by  an  inverse  theory,  make  pru- 
rigo an  abortive  eczema.    These  theoretical  questions  are  obscure. 

Most  methods  of  local  treatment  are  empirical.  General  treat- 
ment varies  according  to  the  opinion  held  of  the  etiology  of  these 
lesions  (see  p.  564). 


FOLDS    OF    HAM    AND    ELBOW. 


317 


STEATOID    AND    SUPERSEBORRHOEIC    PSORIASIS. 

Common  dry  psoriasis  has  a  tendency  to  affect  the  extensor  sur- 
faces of  the  Hmbs,  and  even  confluent  psoriasis  usually  avoids  the 
folds  of  flexion. 

But  there  is  a  steatoid  psoriasis,  also  known  as  the  psoriasiform 
seborrhoeid,  or  nummular  seborrhoeic  eczema  of  Unna,  which  has  a 
distinct  predilection  for  the  flexor  surfaces.  This  was  formerly 
called  atypical  psoriasis,  but  should,  in  my  opinion,  be  named  ste- 
atoid and  superseborrhoeic  psoriasis.  It  forms  round  patches,  from 
a  third  of  an  inch  to  an  inch  in  diameter,  covered  with  a  yellow, 
greasy,  squamous  crust,  which  is  raised  above  the  skin  to  a  variable 
extent ;  from  the  thickness  of  a  piece  of  parchment  to  that  of  a  five- 
shilling  piece.  When  these  squames  are  removed  a  red  epidermic 
surface  is  exposed,  which  is  less  infiltrated  and  bleeds  less  easily 
than  in  common  psoriasis.  The  patches  may  be  few  and  isolated,  or 
occur  in  large  numbers ;  but  they  are  rarely  confluent  except  on  the 
scalp.     The  eruption  never  forms  large  polycyclic  placards. 

Treatment  consists  in  the  application  of  anti-psoriasic  ointments 
with  the  addition  of  sulphur.  The  following  are  three  examples 
of  ointments  of  increasing  strength: — 


(i)  Oil  of  cade  . 
Oxide  of  zinc 
Ichthyol  .  . 
Resorcine  .  . 
Oil  of  birch  . 
Lanoline  .  . 
Vaseline  .  .    . 

(2)  Precipitated  Sulphur   "1 

Resorcine laa 

Oil  of  birch  ....      | 
Oil  of  cade  ....     1 

Vaseline laa 

Lanoline J 

(3)  Precipitated  Sulphur  1 
Oil  of  birch  ....     i^^ 
Chrysarobine 
Oil  of  cade  . 
Lanoline    .     . 
Vaseline     .    . 


-aa       5  grammes 

-aa       I  gramme 

10  grammes 
It  " 


I  gramme 


10  grammes 


I   gramme  I 

50  centigrammes 


-aa     10  grammes 


3  ss 
gr.  48 

5i 
5iss 

gr.  48 

Bi 

gr.  48 
gr.  24 


aa    5i 


3i8  FOLDS    OF    HAM    AND    ELBOW. 

After  cleansing,  solutions  of  chrysophanic  acid  in  chloroform  (i 
in  20)  may  also  be  applied  by  a  brush;  left  to  dry,  and  covered  with 
traumaticin.  But  this  form  of  psoriasis  is  less  resistant  to  treatment 
than  the  common  form,  and  generally  less  liable  to  recur. 


ICHTHYOSIS. 

Even  when  ichthyosis  is  generalised,  rendering  the  whole  surface 
of  the  body  hyperkeratotic,  the  folds  of  the  ham  and  elbow  form 
islands  when  the  skin  is  smooth  and  normal.  This  negative  fact  con- 
stitutes an  important  characteristic,  but  it  is  seldom  mentioned. 


INTERTRIGO.       PARASITIC    ERUPTIONS. 

The  intertrigos,  erythrasmas,  intertriginous  trichophytoses,  which 
have  a  particular  aflfection  for  the  folds  of  flexion  in  general,  occur 
less  often  in  the  folds  of  the  elbow  and  ham,  because  the  bottom  of 
the  fold  is  nearly  always  exposed  to  the  air  as  the  limb  is  not  usually 
flexed.  Nevertheless,  these  affections  occasionally  occur  in  these 
regions,  but  always  in  cases  where  the  primary  lesion  is  in  the 
groin  or  axilla ;  the  lesions  in  the  ham  and  fold  of  the  elbow  being 
secondary. 


SEMEIOLOGY    OF    THE    POPLITEAL    AND    EPITROCHLEAR 

GLANDS. 

The  glands  of  the  ham  and  elbow  present  the  peculiarity  that,  in 
nearly  all  infections  of  the  extremities  of  the  limbs,  they  are  less 
enlarged  and  sensitive  than  the  glands  of  the  root  of  the  limbs. 
They  are  also  the  last  to  be  affected  in  most  diseases  with  general 
glandular  reaction,  such  as  mycosis  fungoides.  The  only  common 
exception  is  the  epitrochlear  gland,  which  is  the  satellite  gland  of 
digital  chancre,  and  is  also  affected  in  the  general  glandular  reaction 
in  secondary  syphilis.  I  have  also  seen  the  popliteal  glands  react  in 
an  adenoid  sarcoma  of  the  foot ;  but  this  is  so  exceptional  as  only  to 
require  mention. 


FOLDS    OF    HAM    AND    ELBOW.  319 

THE    EPITROCHLEAR    GLAND    IN    SYPHILIS. 

The  epitrochlear  gland  may  be  dealt  with  in  this  place,  although  it 
belongs  to  the  posterior  surface  of  the  elbow.  It  is  generally  not 
easily  palpable,  and  is  the  size  of  a  haricot  bean.  In  cases  of  syph- 
ilitic chancre  of  the  finger  (p.  374)  it  is  tripled  in  size,  of  charac- 
teristic hardness  and  easily  felt. 

In  the  course  of  secondary  syphilis  when  generally  polyadenitis  is 
established,  the  epitrochlear  gland  takes  part  in  the  process.  Many 
syphilographers  never  fail  to  seek  for  it.  It  is  doubled  in  size  and 
rather  softer  than  normal ;  but  this  change  is  not  comparable  to  that 
which  it  undergoes  when  it  is  the  satellite  gland  of  digital  chancre. 


THE  FORE-ARM. 

The  fore-arm,  apart  from  the  elbow  and  wrist,  presents  no  der- 
matosis pecuHar  to  itself ;  but  divers  affections  present  a  special 
physionomy  in  this  region. 


One  of  the  most  frequent,  both  in  children  and"" 
adults,   is   the   chronic,   pruriginous,   non-exudative 
eruption,  knozvn  as  chronic  urticaria,  lichen,  pru- 
rigo,  or  strophulus ^ 

Also  the  traumatic  eczemas,  zvhich  originate  on" 
the  hands,  but  extend  to  the  fore-arms 

Among    the    traumatic    eruptions,    there    is    one, 
constituted  by  miliary  pustules,  zvhich  is  peculiar    . 


Chronic  urticaria 
chronic   lichen   .  p.  321 

'i>aumatic  e  c  z  e- 
mas.  Artificial 
dermatitis  ...   p.  321 

Miliar}',       pustular 
.     staphylo  c  o  c  c  i  c 

dermatitis  ....  p.  322 


The  fore-arm  often  presents  primary  or  second- 
ary streptococcic  dermatites,  characterised  by  serous 
exudation  and  thickening  of  the  subjacent  skin   .    . 

This  thickening  may  become  chronic  /tV/j^'Mt.so/ioMLichenisation 
To  this  series  may  be  attached  pyodermatitis,  fur- 
uncles, furuncular  abscess,  impetigo,  and  ecthyma, 
which  are  superadded  or  may  occur  on  the  healthy 
skin 


Exudative    strepto- 
coccic dermatitis  p.  323 


•  P-324 

Furuncle,  Impetigo, 
Ecthyma   ....   p.  324 


.    .    .  Also  lymphangitis,  zvhich  is  more  frequent 
in  the  extremities  than  elsewhere 

There    is   sometimes   seen,    on    the    fore-arm,    a' 
specific,    tuberculous    lymphangitis,    consecutive    to 


r  Lymphangitis 


P-32S 


Tuberculous     Ivm- 


P-325 


p.  326 


tuberculosis   of   the   hand |      P^'^ngitis  . 

Psoriasis,   the   primary   localisation   of  which    is\ 
usually  on  the  elbow,  may  cover  the  external  sur- 1  Psoriasis  .... 
face  of  the  fore-arm 

Erythema    multiforme,    usually    situated    on    thc->i  Erythema        multi- 
hands  and  wrists,  may  extend  to  the  fore-arm   .    .  J      forme p.  326 

The  same  may  occur  with  toxic,  medicamentous^'M  e  die  amenious 
erythemas J      erythema  ....  p.  326 

The  fore-arm  is  often   the  seat  of  the  first  out-  1 
breaks  of  the  painful,  bullous   iermatitis  of  Duhr-  L Dermatitis    herpeti- 
ing-Brocq J      ^^"""^'^ P-  327 

The  first  papules  of  the  lichen  planus  of  Wilson^ 
are  most  often  seen  on   the  fore-arm |Lichen  planus  .  .  .  p.  327 


THE    FORE-ARM.  321 

CHRONIC  URTICARIA.       CHRONIC  LICHEN. 

During  the  first  years  of  life  certain  children  suffer  from  intense, 
paroxysmal  itching  of  the  whole  cutaneous  surface.  A  toxic  origin 
ab  ingcstis  and  the  hereditary  neuropathic  state  have  been  suggested 
as  causes,  without  proof.  Bazin  includes  the  lesions  of  prurigo  or 
lichen  of  this  kind  among  the  benign  scrofulides.  As  a  matter  of 
fact  we  know  nothing  of  the  real  causes  of  chronic  prurigo  or  lichen ; 
these  two  words  are  equivalent  in  French  dermatology  (p.  543). 

Each  attack  often  begins  by  an  urticaria  which  quickly  disappears, 
but  the  pruritus  remains.  Minute  disseminated,  incompletely  devel- 
oped vesicles  occur,  which  have  been  incorrectly  called  acuminate 
papules.  These  are  removed  by  scratching  and  replaced  by  a  small 
dry  scab.  The  first  lesions  disappear  and  are  replaced  by  a  grey 
spot ;  others  arise,  and  a  dry,  hard,  thickened  condition  is  consti- 
tuted, divided  into  squares  by  numerous  folds.  When  this  condition 
is  complete,  with  considerable  thickening  of  the  skin  and  exaggera- 
tion of  its  papular  projections  and  folds,  the  state  of  lichenisation  is 
produced.  The  chronic  urticaria,  in  which  recurrent  attacks  of 
urticaria  predominate,  the  chronic  lichen  of  the  French  authors,  and 
the  chronic  prurigo  of  the  present  day,  are  clinical  terms,  differing 
but  little,  of  a  morbid  condition  which  appears  to  me  to  be  unique. 
But  there  is  no  absolute  proof  of  the  unity  or  of  the  plurality  of 
these  different  clinical  forms,  or  of  the  existence  of  one  or  other, 
the  prurigo  of  Hcbra  for  instance,  as  a  morbid  entity. 

The  treatment  consists  in  the  application  of  zinc  paste,  and  glycer- 
ine of  starch  with  menthol,  when  the  itching  is  intense.  Warm 
douches  are  also  useful  in  these  cases  (Jacqiict).  Also  each  case 
must  be  treated  on  its  own  merits.  If  the  arterial  tension  is  high,  it 
may  be  lowered  by  high  frequency ;  if  tuberculosis  is  suspected  high 
feeding  is  indicated.  If  the  gastric,  hepatic,  pancreatic  or  intestinal 
functions  are  affected  the  cause  must  be  remedied ;  but  not  by 
preconceived  ideas  as  to  the  mechanism  of  these  dermatoses,  of 
which  we  are  ignorant, 

TRAUMATIC    ECZEMAS.       ARTIFICIAL   DERMATITIS. 

All  mechanical,  physical,  or  chemical    irritation  of    the    hands, 
especially  when  repeated,  may  determine  eruptions  which  are  termed 
21 


322  THE    FORE-ARM. 

artificial,  traumatic,  or  occupational.  From  the  hands  they  extend 
to  the  wrist  and,  according  to  their  intensity,  more  or  less  onto  the 
fore-arm.  These  are  better  studied  with  the  region  of  the  hands, 
where  they  invariably  commence.  Certain  substances  provoke  a 
reaction  which  is  almost  specific,  such  as  castor-oil,  or  turpentine, 
which  causes  a  superficial  miliary  phlyctenisation  passing  on  to  sup- 
puration. Others  give  rise  to  lesions  which  are  clinically  and  ana- 
tomically indistinguishable  from  those  of  eczema ;  others  again  cause 
eruptions  which  are  microbial  from  the  first,  in  spite  of  their  trau- 
matic origin;  this  being  favourable  to  the  pullulation  and  implanta- 
tion of  microbes  pre-existing  on  the  surface.  The:fe  types  will  be 
studied  successively.  Whatever  characters  the  irritation  assume, 
they  generally  yield  to  removal  of  the  cause,  and  under  the  influence 
of  moist  dressings  with  boiled  water  renewed  twice  a  day  for  sev- 
eral days.  The  newly  formed  epidermis  is  red  and  shiny  and  may 
be  covered  with  zinc  paste  to  complete  the  cure.  But  if  the  exciting 
cause  is  renewed  the  lesions  will  recur. 


PUSTULAR  MILIARY  DERMATITIS. 

Pustular  miliary  aermatitis  of  the  back  of  the  hands  and  fore- 
arms is  always  of  traumatic  origin,  and  is  seen  in  washerwomen, 
dyers,  etc.  The  skin  is  red,  dry  and  thickened,  and,  when  closely 
examined,  is  seen  to  be  riddled  with  miliary  pustules,  the  largest  of 
which  are  smaller  than  a  grain  of  barley  and  the  smallest  the  size 
of  the  eye  of  a  needle.  Owing  to  the  thickening  of  the  skin  the  pus- 
tules do  not  project,  but  appear  to  be  imbedded.  Most  of  these  pus- 
tules develop  round  a  hair  follicle,  others  are  scattered  anywhere. 
Their  number  is  sometimes  very  large,  and  twenty  or  more  may 
occur  on  an  area  half  an  inch  square.  This  dermatitis  is  quite  dry 
and  the  pustules  do  not  open.  Treatment  consists  in  moist  dress- 
ings and  zinc  paste. 

The  mechanism  of  the  dermatitis  appears  to  be  as  follows:  On 
the  surface  of  the  skin,  especially  in  the  follicular  orifices,  there  are 
a  number  of  staphylococci ;  irritation  of  the  skin  reduces  its  power 
of  resistance  and  the  staphylococci  multiply  and  cause  pustular  fol- 
liculitis. This  eruption  is  usually  caused  by  the  staphylococcus  with 
grey  culture,  but  sometimes  by  the  staphylococcus  aureus. 


i 


v.-^ 


THE   FORE-ARM. 


323 


EXUDATIVE  IMPETIGINOUS  DERMATITIS. 

The  artificial  dermatites  of  the  type  of  true  eczema  (p.  560) 
after  a  few  days  change  their  aspect;  the  serous  discharge  increases 
and  gives  rise  to  a  thin  yellow  crust.  Under  this  crust  is  found  the 
pale  lilac,  sero-fibrinous  exudation  characteristic  of  streptococcic 
infection,  and  the  culture  demonstrates  the  presence  of  this  organ- 
ism. The  process  consists  in  an  impetiginisation  of  a  simple  epi- 
dermitis  provoked  by  previous  traumatism. 

These  forms  of  exudative  dermatitis,  especially  when  kept  up  by 
repetition  of  the  initial  trauma,  may  last  for  many  months,  and  is 


Fig.  133.     Acute  vesicular   eczema.      (Brocq's   patient.     Photo,    by   Sottas.) 

then  followed  by  subjacent  infiltration,  which  becomes  gradually 
harder  and  ends  in  lichenisation  of  the  skin.  But  some  exudation 
always  remains  on  the  surface  of  the  thickened  and  papular  integu- 
ment. 

The  amber-coloured  powdery  crusts  and  a  trace  of  exudation 
revived  by  the  crises  of  pruritus,  show  that  this  lichenisation  is  sub- 
sequent to  a  primary  eczematisation ;  thus  differing  clinically  from 
that  of  the  lichenisation  of  prurigos,  v/hich  arises  without  previous 
eczematisation. 

In  the  acute  period  moist  dressings  may  be  used ;  later  on  repeated 
applications  of  nitrate  of  silver  (i  in  15)  and  zinc  ointments.     If 


324  THE    FORE-ARM. 

infiltration  and  lichenisation  are  established,  the  surface  should  be 
protected  from  the  air  by  zinc  paste.  The  acute  period  is  of  short 
duration,  but  resolution  of  the  chronic  infiltration  and  of  the  liche- 
noid cutaneous  induration  persist  for  several  months. 

LICHENISATION    OF    CHRONIC    DERMATOSES. 

The  preceding  paragraphs  show  that  the  thickening  of  the  skin 
and  its  hard  infiltration  and  hypertrophy,  which  are  manifested 
externally  by  the  lichenoid  and  papular  transformation  of  the  sur- 
face, are  not  specific  for  a  single  dermatosis.  It  appears  that  cuta- 
neous lichenisation  only  represents  a  mode  of  reaction  of  the  skin 
like  eczematisation.  It  constitutes  a  form  of  reaction  to  chronic 
irritation,  such  as  pruritus,  or  any  other  trumatism  of  the  surface, 
even  microbial;  but  we  do  not  know  why  certain  severe  forms  of 
pruritus  of  extremely  chronic  nature  may  never  be  accompanied 
by  it. 

FURUNCLES.     FURUNCULAR   ABSCESS.     ECTHYMA. 

The  importance  of  traumatism  in  the  production  of  microbial 
epidermatitis  having  been  shown  by  the  preceding  facts,  it  is  not  sur- 
prising that  the  fore-arm  should  be  a  seat  of  predilection  for  the 
agents  of  pyodermatitis.  The  staphylococcus  aureus  causes  fur- 
uncle and  furuncular  abscess ;  the  streptococcus  gives  rise  to 
ecthyma,  which  is  only  an  ulcerative  impetigo. 

Furuncle  on  the  hand  and  fore-arm  is  often  the  result  of  miliary 
pustular  dermatitis,  which  we  have  already  mentioned.  As  it  is 
rather  more  frequent  on  the  hand,  it  will  be  referred  to  with  that 
region.  Furunculous  abscess  is  only  the  necrotic  core  of  a  furuncle 
increased  by  a  layer  of  pus.  Ecthyma  commences  on  the  fore-arm. 
as  on  the  hand,  by  a  phlyctenular  impetigo  which  is  transformed 
into  an  ulcer,  by  want  of  care  and  by  traumatism. 

All  these  microbial  lesions  are  congested,  and  painful,  and  are 
accompanied  by  oedema,  due  to  the  dependent  position  of  the  arm, 
and  are  benefited  by  rest  of  the  limb  in  a  sling,  and  moist  dressings. 
Furuncle  is  treated  in  the  way  described  on  page  347.  Ecthyma  may 
be  dressed  with  ointment  of  sub-carbonate  of  iron  (i  in  40),  which 
causes  rapid  healing. 


THE   FORE-ARM. 


325 


LYMPHANGITIS. 


All  septic  lesions  of  the  hand,  wrist,  and  fore-arm  are  accom- 
panied by  marked  inflammatory  oedema  and  lymphangitis.  The 
latter  forms  red  lines,  following  the  course  of  the  peri-venous  lym- 
phatics. Lymphangitis  necessitates  rest  of  the  limb  in  the  horizontal 
position,  prolonged  warm  baths  or  moist  dressings.  It  usually  ends 
m  resolution,  even  when  intense,  as  does  the  axillary  adenitis 
which  accompanies  it.     However,  extensive  sub-cutaneous  abscesses 

sometimes  develop,  requiring  surgical 

treatment. 

TUBERCULOUS  LYMPHANGITIS. 

Tuberculous  lymphangitis  of  the 
fore-arm  is  a  rarity.  It  may  follow 
a  tuberculous  ulceration  of  the  hand, 
a  severe  lupus,  or  a  tuberculous  ulcera- 
tion due  to  external  inoculation.  It 
generally  forms  a  hard  cord  under  the 
skin,  more  or  less  in  the  course  of  a 
vein,  and  sometimes  mistaken  for  it. 
This  cord  is  nodose,  irregular  and 
moniliform.  Sometimes  one  of  the 
nodosities  softens  and  forms  an  open 
ulcer.  These  conditions  are  seldom  seen 
except  in  cases  of  advanced  phthisis  with 
cachexia,  and  are  terminated  by  pul- 
monary tuberculosis.  I  have,  however, 
seen  a  case  in  a  person  in  good  health, 
consecutive  to  a  tuberculous  ulceration 
of  the  palm ;  of  chronic  slow  evolution, 
with  non-suppurative  axillary  adenitis, 
but  without  general  infection. 

Treatment  should  consist  in  photo- 
therapy of  each  nodosity  and  of  the 
whole  lymphatic  tract.  In  default  of  this, 
ii,..i34.  Tuberculous  i^ymphan- ^^^ision  of  the  whole  Ivmphatic  tract 
£outs  H"sp°Mreurn':"No"i99-o  ^^Ith  the  uodositics  should  be  practiscd. 


3^6 


THE   FORE-ARM. 


PSORIASIS. 

Psoriasis,  primarily  situated  on  the  elbow,  may  cover  the  ex- 
tensor surface  of  the  fore-arm  with  dry  squamous  lesions  scat- 
tered like  drops  of  wax  on  the  skin.  These  preserve  their  char- 
acter of  absolute  dryness  and  their  laminated  structure.  \Mien 
the  squame  is  raised  the  subjacent  epidermis  bleeds  slightly.     By 


rig.  135.     Psoriasis    guttata.      (Jeanselme's  patient.     Photo,  by  Noirfe.) 

these  characters,  the  extension  of  the  lesions,  or  their  generalisa- 
tion in  other  regions,  their  indolence  and  chronicity,  psoriasis 
cannot  be  mistaken. 

ERYTHEMA    MULTIFORME. 

Erythema  multiforme  is  an  affection  which  is  naturally  localised 
to  the  extremities;  the  wrists,  hands  or  fingers,  and  seldom  occurs 
on  the  fore-arms  except  by  extension.  It  requires  in  this  region  no 
particular  consideration  as  regards  etiology  and  treatment  (p.  244) 


ERYTHEMA    MEDICAMENTOSA. 

The  fore-arm  is  often  the  seat  of  medicamentous  eruptions;  the 
rubeoliform  and  pruriginous  eruption  of  quinine;  the  large  flat,  red 


THE    FORE-ARM.  327 

and  pigmentary  maculo-papules  of  antipyrin,  etc.  These  toxic  erup- 
tions are  nearly  always  characterised  by  some  anomaly ;  for  instance, 
the  large,  flattened,  purple,  framboesiform  tuberosities  of  bromides, 
iodides,  etc.  They  must  always  be  thought  of  in  eruptions  having 
strange  characters  which  do  not  conform  to  any  ordinary  category. 


DERMATITIS    HERPETIFORMIS. 

This  complex  morbid  type  has  no  fixed  localisation  and  belongs 
to  the  generalised  dermatoses  (p.  605.  Sometimes,  however,  its 
painful  and  bullous  lesions  occur  on  the  fore-arm.  It  occurs  in  two 
principal  forms ;  the  one  herpetic,  formed  of  multiple  circles ;  the 
other  bullous,  constituted  by  crops  of  successive  bullae,  some  of 
which  are  in  a  state  of  ulceration  while  others  are  forming;  while 
the  first  have  left  only  a  pigmentary  trace.  The  general  condition 
is  good  and  the  cause  unknown.  The  patient  has  usually  had  similar 
attacks  before,  which  assist  the  diagnosis.    For  treatment  see  p.  605. 


LICHEN    PLANUS    OF    WILSON. 

Lichen  planus  is  a  generalised  dermatosis  (p.  553),  but  merits  a 
few  words  here,  for  the  internal  surface  of  the  fore-arm  is  perhaps 
the  most  common  situation  of  its  first  elements.  They  appear  first 
as  fine  papules  disposed  in  small  islands.  These  papules  are  reddish- 
yellow,  flat  and  shiny  and  traversed  by  peculiar  grey  lines.  They 
often  remain  stationary  for  several  months.  The  eruption  becomes 
more  or  less  generalised  in  different  cases.  Lichen  planus,  as 
already  stated,  has  no  specific  treatment ;  the  symptomatic  treatment 
will  be  considered  later  (p.  553). 


THE    WRIST. 

The  wrist  is  not  a  dermatological  region  which  presents  autono- 
mous eruptions. 


Erythema  multiforme  alone  may  be  limited  enA 
tirely   to    this  region,   but  more   often  invades   thel      -^^"^^ 
hand  and   even   the   fore-arm forme  . 

Scabies  may  present  a  marked  localisation  on  the' 
wrists,  characterised  by  burrows  and  abundant 
vesico-pustules,  but  these  lesions  accompany  others 
situated  elsewhere 

Trichophytosis  may,  by  chance,  shozv  on  the 
wrist,  one  or  two  red  vesiculo-pustular  patches 
more  or  less  inflamed 

Artificial  dcrmatites  arise  on  the  hand  and  in- 
vade the  fore-arm;  they  are  not  localised  on  the 
zvrists,  although  they  invade  them 

Papulo-necrotic  tuberculides,  described  under  so' 
many    names    {acnitis,    atrophic    folliculitis,    etc.) 
when  they  form  localised  eruptions,  have  often  the 
wrist   as   their  seat   of  election 

/  shall  conclude  by  saying  a  feiv  zcords  on  lichen' 
planus,  not  that  it  presents  any  election  for  the 
wrist,  but  because  it  often  shows  its  most  char- 
acteristic elements  on   the  palmar  surface  .... 


multi- 


p.  32H 


Scabies p.  ^2g 

Trichophytosis   .   .   p.  .^30 

Traumatic     derma- 
titis     p.  331 


TuberciUides 


Lichen  planus 


P-  331 


P-33I 


ERYTHEMA    MULTIFORME. 


Erythema  multiforme  has  for  its  seats  of  predilection  the  wrists 
and  ankles.  From  the  wrists  it  often  extends  to  the  hands  and  fore- 
arms, but  the  wrist  remains  the  usual  place  of  appearance  in  the 
first  lesions.  Erythema  multiforme,  usually  secondary  to  a  benign 
infection  most  often  of  pharyngeal  origin,  is  often  preceded  by  some 
malaise,  but  the  appearance  of  the  first  lesion  may  be  the  first  symp- 
tom. These  lesions  consist  of  round,  rose-coloured  spots  with  a 
livid  centre,  in  the  form  of  a  rosette.  The  eruption  varies  in  inten- 
sity and  may  consist  of  10  patches  or  200;  usually  from  i  to  15  on 
each  wrist.  The  spots  may  be  raised  at  the  edge,  phlyctenular  and 
even  bullous  in  the  centre.     The   situation  of  the  lesions  on  the 


THE   WRIST. 


320 


ankles,  wrists  and  neck  is  very  typical.  The  treatment  is  almost  nil ; 
and  it  is  one  of  the  most  benign  eruptions.  The  cause  must  be 
searched  for  to  prevent  recurrence. 


SCABIES. 


The  lesions  of  scabies  on  the  wrists  constitute  one  of  the  most 
typical,  and  the  most  necessary  to  know,  of  the  morbid  manifesta- 
tions of  this  region.  They  may 
be  more  marked  on  the  wrists 
than  in  the  interdigital  spaces 
and  on  the  hand. 

The  wrist  is  especially  aflFected 
on  the  palmar  surface,  at  the 
fold  of  flexion.  The  lesions  con- 
sist of  burrows,  intact  and  open 
vesicles.  If  the  lesions  are  in- 
fected, pustules,  phlyctenules  of 
impetigo  and  even  ecthyma  may 
occur. 

(i)   The  burrows   are   chiefly 
directed    transversely ;    they    are 
about  %  to  y2  an  inch  in  length, 
as  fine  as  the  stroke  of  a  pen,  of 
a  deep  grey  colour,  and  irregu- 
lar as  a  worm  track  in  wood. 
(2)    The  vesicles,  usually  very  small  in  scabies,  may  be  larger  on 
the  wrist,  where  the  skin  is  fine  and  expansible.    They  are  clear  and 
slightly  acuminated. 

(4)  Vesicles  after  suppuration  increase  in  size  and  remain  mixed 
with  clear  and  non-infected  vesicles.  This  mixture  is  very  char- 
acteristic. 

(5)  The  streptococcic  phlyctenules  of  impetigo  are  larger,  less 
numerous,  and  often  emptied  of  their  turbid  contents. 

The  treatment  of  scabies  is  the  same  here  as  elsewhere.  The 
treatment  of  pustular  scabies  will  be  mentioned  with  the  hand 
(P-  344)- 


Fig.  136.  Scabies  of  the  wrist,  show- 
ing burrows.  (Hallopeau's  patient. 
St.   Louis  Hosp.   Museum,   No.  1947.) 


330 


THE   WRIST. 


TRICHOPHYTOSIS. 


The  region  of  the  wrist,  owing  to  its  thin  skin  and  its  exposure 
to  traumatism,  i«  often  the  seat  of  trichophytic  inoculations  of  ani- 
mal origin.  Sometimes  this  consists  of  a  round  raised  placard  of 
suppurating  trichophytic  follicles,  of  equine  origin.  This  form  is 
most  common  on  the  back  of  the  hand  (p.  346).  Or  there  may 
be  a  vesiculo-pustular  trichophytosis,  in  the  form  of  a  single  or 
double  circle  (Herpes  iris  of  Bictt,  Fig.  137),  which  appears  to 
originate  in  the  cat.  This  parasite,  like  that  of  Kerion,  belongs 
to    the    group    of    trichophytons    with  white  culture.        At    other 

times  the  trichophyton  has 
variable  forms  and  is  of 
varied  origin,  the  family  of 
trichophytons  presenting  a 
great  variety  of  species. 

Trichophytosis  is  recog- 
nised by  the  circinate  form 
of  the  lesions,  which  are 
vesicular  or  vesiculo-pus- 
tular at  the  margin,  poly- 
circinate  by  fusion  of  sev- 
eral circles,  few  in  number 
and  generally  localised  in 
one  region. 

The  treatment  consists  in 
the  application  of  iodine, 
which  should  be  in  weak 
solution  when  the  lesions 
are  inflammatory.  Two 
parts  of  tincture  of  iodine 
to  4  parts  of  alcohol 
(60%)  is  suitable  for 
ordinary  cases,  applied  vig- 
orously so  as  to  decorticate 
the  vesicular  elements.  In 
Fig.  137.    Vesiculo-pustular^  ^^1^*''     '^"'^^°-      inflammatory  cases  the  so- 

(Quinquaud's  Patlent^     1^160°"'"  """'P-  ^"^«"'"'        lution    is    diluted    tO    I    in    5 


THE   WRIST. 


331 


or  I  in  10  and  alternated  with  moist  dressings.    The  cure  should 
not  take  more  than  three  weeks,  and  in  mild  cases  a  week. 

TRAUMATIC    DERMATITIS. 

Traumatic  dermatitis  arises  on  the  hand  and  extends  by  the 
wrist  to  the  fore-arm.  In  average  cases  the  lesions  occupy  exactly 
the  surface  covered  by  a  glove,  and  stop  at  the  wrist.  Traumatic 
dermatitis  of  whatever  origin  has  no  particular  autonomy  in  the 
wrist.    It  is  studied  with  the  regions  of  the  hand  and  fore-arm. 


TUBERCULIDES. 

The  wrist  is  a  seat  of  election  for  localised  eruptions  of  tubercu- 
lides.   Although  these  may  differ  morphologically  in  different  cases, 

they  all  have  a  family  resemblance, 
which  renders  them  easily  recognisable 
by  anyone  who  has  attentively  studied 
a  single  case. 

They  are  constituted  by  papular  ele- 
ments of  a  brownish  purple  colour, 
which  leave  cicatrices  surrounded  Ijy 
hyperpigmentation.  They  are  papulo- 
necrotic eruptions,  with  a  crust  in  the 
centre  of  the  retrogressive  papules.  The 
red  or  purple  papules  and  the  brown 
cicatricial  traces  of  former  erosions, 
mixed  together  in  an  irregular  group, 
constitute  for  the  tuberculides,  in  this 
region  especially,  a  characteristic  ap- 
pearance. The  long  duration  in  the 
place  of  the  eruption  and  the  stigmata 
of  tuberculosis  support  the  diagnosis. 

LICHEN  PLANUS. 


Fig:.  1.S8.  Papulo-necrotic  tuber- 
culides (acnitisl.  (Besnier's 
patient.  St.  Louis  Hosp.  Mu- 
seum,   Nn.    1508.) 


Lichen  planus  has  no  predilection  for 
the  wrist;  it  is  a  general  dermatosis, 
but  on  the  palmar  surface  it  often  pre- 


33^  THE   WRIST. 

sents  its  elementary  characters  perfectly.  It  often  occurs  here  as  a 
group  of  papules  around  a  larger  one.  All  the  papules  are  reddish 
yellow  or  violet,  flat,  shiny  and  projecting  for  half  a  millimetre 
above  the  surface.  The  larger  elements  are  intersected  by  fine 
white  lines  included  in  the  thickness  of  the  papules  themselves, 
and  quite  pathognomonic.  But  the  eruption  has  always  a  tendency 
to  become  generalised  and  cover  the  entire  body  and  limbs. 


THE    BACK    OF    THE    HANDS. 

The  back  of  the  hands  presents  a  different  pathological  derma- 
tology to  that  of  the  palmar  surface. 

In  the  child  and  adolescent  is  seen  the  purple  I  Erythema  pernio. 
erythema  due  to  cold  zvhich  is  accompanied  or  not  Y  Chilblains.  Fis- 
hy  true  chilblains,  fissures  and  rhagades I      sures p.  335 

In  the  child  and  adult  occur  attacks  of  erythema'^Krythema  multi- 
known  as  erythema  multiforme J  forme P- 336 


In  adolescence,  or  in  adult  age,  may  occur  the~\ 

....       ...         .     .                .^     .    I  Verrucose    tubercu- 
losis    p.  336 


diverse  forms  which  local  tuberculosis  may  effect;  I 
warty    tuberculosis    and    anatomical    tubercle   ■    •    •  j 

.    .    .  And   true   lupus  in   its   three   forms;   flat' 
raised  and  ulcerative;  the  latter  leading  to  tnutila 
tion 


-Lupus p.  337 


With  local  tuberculosis,  we  shall  deal  with  angi-^ 

,  ,  .  ,  •  ,  ,     Angiokeratoma     of 

okeratoma,   multiple   verrucose   ncevi,   on   the   back  y 

r  „      r  J   1      J  Mibelli p.  338 

of  the  fingers  and  hands J 

.    .    .  And    especially    with    the    eruptive    tuber-"\ 
culides'  {acne    cacheticorum)    and   the   deformities  i-TuhercuVides  .   .   .  p.  338 
of  the  hand  which  may  accompany  them J 

/  shall  say  a  fezv  words  concerning  leprous  hands'\ 
in   mutilating   leprosy J 

[-Sclerodactylia    .    .    p.  339 


.    .    .  and  sclerodactylia,   although   it  begins   on 
the  fingers  and  becomes  generalised  over  the  body 


The  hand  is  a  seat  of  election  for  the  achromic 
patches  of  vitiligo,  without  vitiligo  being  limited 
to   this  region 

Also  for  melanodermia,  which,  in  general  is 
more  marked  on  uncovered  regions 


Vitiligo p.  340 

Melanodermia   .   .   p.  341 


Xeroderma    pigmentosum,    which    is    a    kind    of^ 

.  Xeroderma       p  i  g- 

malignant    lentigo,   is   localised   exclusively    on    the  I     „„  .       „ 

'^  ''  '  r     mentosum    ...  p.  341 

face  and  hand^ J 


334  THE    BACK    OF    THE    HANDS. 

The  hands  are  the  seat  of  election  of  traumatic-^  Traumatic  dermati- 
dcnnatites  of  external  origin J     tis p.  341 


The  back   of  the  hands  present  also  a  singular-^ 
form  of  nummular  eczema,  which  may  be  primary 
or  secondary 


Nummular    eczema  p.  342 


Attacks  of  dyshidrosis  arc  also  seen  on  the  back) 

,     ,       ,       ,                   ,           ,        ,  r  Dyshidrosis  ....  p.  344 

of   the   hands   more   titan   elsewhere J  x-     -r-r 

The   hand    is    one    of    the   seats   of   election    of^ 

scabies,  and  we  shall  consider  the  symptoms  it'/uV/i  I  Scabies p.  344 

it  presents J 

The  back  of  the  hands  is  also  one  of  the  scats') 
cf     election     of    follicular     trichophytosis,     called  I  Kerion  Celsi   .  .     .p.  346 
Kerion   Celsi J 

The  vesicular,  eroded  or  crusted  elements  of  im-^  Impetigo    c  o  n  t  a- 
pctigo  contagiosa  are  often  seen  here J      giosa p.  346 


vncular  abscess J 


Also    furuncles,    carbuncle    and    peri-fur-~i 

,  y  Furunck 

abscess J 

The  back  of  the  hands  is   one  of  the  seats  of-\ 

,.         ^         ^   ,  ,     ,  LMalignant  pustule  p.  347 

election  of  malignant  pustule,  or  charbon   ...    .J 


.  .  .  also  of  Oriental  boil,  named  after  different' 
regions — Biskra  button,  Aleppo  boil,  annamite 
ulcer,  etc 


■  Oriental  Boil  .  .  ;  .  p.  348 


.    .    .  also  of  common  zcarts  and  flat  zcarts  .    .    Warts p.  349 

Pellagroid  erythema,  zvith  oedema  and  shedding} 

cf  the  horny  epidermis,  is  localised  typically  on  the  r 

'  •*     '  ^t        y  ma p.  350 

lack  of  the  hand J 

In   conclusion   we   shall  say   a   few  words   conA 

ccrning  oedema  of  the  hand,  zvhich  is  so  common  |-Oedema P- 35^ 

i:i  dermatological  and  other  morbid  states  ...    .J 

.    .    .  and    atrophic    telangiectasic    dermatitis    of]  ^^        .    ,, 

Chronic  X-ray  der- 
the   hands  in   persons   exposed   to    the   action   of  I 

matitis p.  351 

the  X-rays J 


THE    BACK    OF    THE    HANDS. 


335 


ERYTHEMA    PERNIO.       CHILBLAIN. 


The  name  of  this  erythema  indicates  its  nature.    It  is  due  to  cold. 

It  forms  an  enor- 
mous chilblain  on 
the  back  of  the 
hand,  sometimes 
extending  to  the 
fingers ;  at  other 
times  it  accom- 
panics  distinct 
chilblains  of  the 
fingers. 

Erythema  per- 
nio occurs  in  the 
form  of  a  mas- 
sive oedema.  The 
dorsal  surface  of 
the  hand  is  swol- 
len and  red,  with 
wrinkled  and  des- 
quamating e  p  i- 
dermis.  The  epi- 
dermis may  even 
b  e      phlyctenular 

(Fig-  139).  The 
hand  is  cold. 

This  form  of 
erythema,  like 
chilblains,  is  of 
obscure  origin ; 
bad  circulation, 
and  ill-defined 
causes  under  the 
names  of  lym- 
phatism  and 
scrofula. 
General  treat- 
ment  is  tonic,   with   iodine.     Locally,   glycerine   dressings. 


Flgr.  139. 

(Besnier's     patient. 


Erythema    pernio. 

St.     Louis     Hosp.     Museum, 
No.    636.) 


3oO  THE    BACK    OF    THE    HANDS. 

FISSURES.       RHAGADES    A    FRIGORE. 

Cold  in  certain  subjects  causes  chilblains  or  erythema  pernio; 
in  others  it  determines  painful  fissures  (chaps),  which  bleed  on  the 
least  movement.  They  are  especially  common  and  painful  in  those 
subject  to  manual  labour  requiring  frequent  immersion  in  water. 

Treatment  consists  in  removal  of  the  cause  and  the  application 
of  glycerole  of  starch  with  resorcine  ( i  in  30) .  This  should  be 
continued  till  cessation  of  cold,  and  applied  every  night. 

ERYTHEMA    MULTIFORME. 

The  seats  of  election  of  erythema  multiforme  are  the  wrists  and 
ankles,  the  dorsal  surface  of  the  hands  and  fingers,  and  the  lateral 
surface  of  the  neck.  It  appears  to  be  a  toxic  erythema,  usually  origi- 
nating from  the  tonsils.  It  often  appears  suddenly  4  to  8  days 
after  a  slight  pharyngitis,  occurring  on  the  backs  of  the  hands  and 
wrists  in  the  form  of  rose-lilac  spots,  generally  circular,  in  the  form 
of  a  rosette;  with  a  bistre  centre,  a  livid  middle  zone  and  a  rose- 
coloured  border.  This  eruption,  which  includes  10  to  15  patches  of 
different  sizes,  but  all  similar,  is  complete  in  2  or  3  days  with  very 
slight  local  phenomena ;  sometimes  slight  arthralgia  and  shivering. 
It  persists  for  5  or  6  days,  after  which  the  spots  fade  away  in  the 
order  of  their  appearance.  It  may  be  very  benign  and  limited  to  a 
few  rose-coloured  spots  without  the  rosette  appearance ;  or  more 
severe,  with  peeling  of  the  epidermis.  In  some  cases  the  spots  become 
phlyctenular  or  bullous  (p.  604) 

Local  treatment  is  palliative  and  symptomatic,  and  consists  in 
powders  and  pastes.  The  tonsils  must  be  treated  if  the  angina  recurs, 
for  the  erythema  often  recurs  with  it. 

VERRUCOSE  TUBERCULOSIS.  ULCERATIVE  TUBERCULOSIS. 

External  tuberculosis  is  most  often  contracted  by  a  phthisical 
subject  from  contact  of  the  hand  with  the  saliva.  It  occurs  on  the 
back  of  the  hand  in  the  form  of  an  irregular  lesion  with  a  dry  papil- 
lomatous and  warty  surface ;  easily  excoriated,  slightly  painful  and 
slowly  extensive.  It  forms  the  "anatomical  tubercle"  of  the  hand. 
Sometimes  the  surface  tends  to  ulceration ;  sometimes  even  mutilat- 
ing ulceration. 


THE    BACK    OF    THE    HANDS. 


2i7 


T\v;.  140.     Anatomical     tubf-rcle. 
(Besnier's    patient.      St.    Louis    Hosp.    Museum,    No.    936.) 

The  first  form  is  the  less  severe  and  is  cured  by  the  sharp  spoon. 
If  it  recurs  the  galvano-cautery  may  be  apphed.  The  ulcerative 
form  is  more  severe.  Destruction  by  the  galvano-cautery  was  hith- 
erto the  best  method  of  treatment,  but  required  extensive  application 
to  prevent  recurrence.  Phototherapy  heals  these  forms  of  ulcera- 
tion, and  surgical  methods  should  only  be  used  when  phototherapy 
is  inapplicable  (p.  21). 

LUPUS    VULGARIS. 

Besides  the  above  forms,  the  hand,  like  other  uncovered  regions, 
is  often  attacked  by  lupus  vulgaris.  It  occurs  in  three  forms :  intra- 
cutaneous and  non-exuberant ;  exuberant  and  fungating ;  ulcerative 
and  destructive.  It  has  the  same  characters  and  evolution  as  lupus 
of  the  face  (p.  20). 


Fig.  141.     Mutilating    lupu.s.      (Besnier's  patient.     St.  Louis  Hosp.  Museum,  No.  943.) 


338 


THE    BACK    OF    THE    HANDS. 


The  prognosis  is  the  same  and  it  has  the  same  therapeutic  indica- 
tions. Intervention  should  not  be  delayed,  because  impotence  of 
the  hand  occurs  rapidly,  and  sometimes  the  ulceration  becomes 
mutilating  (Fig.  141). 

ANGIOKERATOMA    OF    MIBELLI. 

This  is  an  affection  which  has  a  tendency  to  become  more  and 
more  connected  with  the  tuberculides.  It  has  the  appearance  of  a 
multitude  of  small,  stellate  vascular  nsevi,  and  is  more  frequent  on 
the  back  of  the  fingers  than  on  the  hands  (p.  365). 


ERUPTIVE    TUBERCULIDES. 

Tuberculous   infection   may   manifest   itself   only  by   a   more   or 
less  generalised  eruption  of  papular  tuberculides.    The  tuberculous 


Fig.  142.     Papulo-necrotic    tuberculides    in    a    child. 
(Sabouraud's    patient.      Photo,    by    Noir6.) 

affection  of  the  subject  leads  to  a  general  cachectic  state,  with  a 
generalised  eruption  of  papular  tuberculides,  analogous  to  those  of 
the  wrist. 


THE    BACK    OF    THE    HANDS.  339 

This  condition  requires  no  local  treatment  and  the  general  treat- 
ment is  that  of  tuberculosis  in  general. 

The  bones  were  shown  to  be  normal  by  radiography. 

LEPRA. 

Although  this  book  avoids  almost  completely  the  study  of  exotic 
diseases,  leprosy  plays  too  important  a  part  in  general  and  cutaneous 
pathology  for  its  characteristic  lesions  not  to  be  mentioned. 


Fig.  143.     Mutilating    leprosy    of   the   hands. 
(Jeanselme's  patient.     Photo,  by  NoirS.) 

The  tendinous,  arthropathic  and  osseous  lesions  of  the  extremities 
are  too  well  shown  in  the  figure  to  require  explanation.  The  lesions 
may  be  only  deforming,  or  at  the  same  time  deforming  and  ulcera- 
tive. In  any  case  when  this  period  has  arrived  diagnosis  has  long 
been  made  by  the  cutaneous  eruptions,  nervous  disorders  and  facial 
lesions,  which  will  be  considered  later  on  with  the  disease  in  gen- 
eral  (p.  655). 

SCLERODACTYLIA. 

Sclerodactylia  commences  on  the  hands  and  fingers,  but  is  not 
localised  to  these  parts.     Its  history  will  be  given  with  the  geneiiiic 


340 


THE    BACK    OF    THE    HANDS. 


dermatoses  (p.  615) .    It  generally  begins  in  women  about  the  fortieth 

year,  by  a  hard  thicken- 
ing of  the  skin  of  the  fin- 
gers, like  a  hard  oedema 
or  a  pachydermia,  the 
skin  appearing  yellow, 
with  the  colour  and  semi- 
transparency  of  old  wax. 
This  condition  gives  rise 
to  fibrous  contraction  of 
the  dermis,  and  while  the 
hand  is  still  in  the  first 
stage  of  the  disease  and 
appears  round  and  plump, 
the  fingers  have  become 
spindle  shaped. 

The  course  of  the  dis- 
ease is  very  slow.  It 
causes  atrophy  of  the  pha- 
langes and  successive  loss 
of  the  ends  of  the  fingers. 
The  half  absorbed  bone 
of  the  phalanges  often 
remains  surrounded  by 
a     circle     of     soft     fun- 

gosities  (Fig.  165).    The  disease  ends  always  in  cachexia  and  death. 

No  treatment  is  of  any  avail. 

VITILIGO. 


Fig.  144.     Sclerodactylia. 

patient.         St.       Louis      Hosp. 
No.    1193.) 


(Quirmuaud's 


'^^ 


The  hand,  like  the  face,  is  one  of  the  seats  of  election  of  vitiligo. 
The  general  history  of  this  aflfection  will  be  considered  later  (p.        ) . 

It  is  characterised  by 
large  irregular  patch- 
es of  white  skin,  sur- 
rounded by  an  excen- 
trically  diminishing 
zone  of  hyperchro- 
mia.    The  disease  is 

145.     Vitiligo   of   the   upper   limbs   in   a  syphilitic,      glow  in  evolutlou   and 
(Darier's  patient.) 


THE    BACK    OF    THE    HANDS.  341 

allied  to  dyscromia  and  melanodermia.  It  is  often  impossible  to 
discover  a  cause  for  vitiligo,  but  it  may  follow  syphilis  and  other 
infections   and   also  trauma. 

MELANODERMIA. 

Melanodermia  will  be  studied  in  the  chapter  on  Dyschromia,  with 
the  general  dermatoses,  although  most  cases  have  a  predilection  for 
the  head,  neck  and  hands.  The  best  known  example  of  this  class  is 
Addison's  disease. 

XERODERMA    PIGMENTOSUM. 

This  is  a  malignant,  consanguineous  and  hereditary  lentigo,  ocoLtr- 
ring  especially  on  the  face  and  the  back  of  the  hands.     It  has  been 

described  in  the  section  of  the  face. 
The  dermatosis  consists  in  a  se- 
ries of  innumerable  hyperchromic 
spots,  which  increase  in  number  from 
year  to  year.  Some  of  the  spots 
atrophy  and  are  replaced  by  a  cica- 
trix, others  give  way  to  epithelial  or 
sarcomatous  degeneration,  some  of 
which  are  eventually  fatal. 

TRAUMATIC  ECZEMA. 
OCCUPATIONAL  DERMATITIS. 

Workmen  are  exposed  by  a  num- 
ber of  manual  occupations  to  trau- 
matic dermatitis,  which  is  character- 
ised by  having  its  maximum  inten- 
sity on  the  hands  and  wrists,  and 
diminishing  progressively  on  the 
fore-arm.  The  chief  victims  are 
cooks,  washerwomen,  photographers, 
printers,  masons,  etc.  The  trauma- 
tism may  be  due  to  too  frequent  im- 
mersion in  soapy  water,  or  result 
_.    ,.^    .^      -  ,        ^  from  contact  with  chemical  agents, 

ngr.  146.     Xeroderma    pigmentosum.  » 

H^sp"''Mus'lum.''^No."*i464^)-    '^°"''  ^uch  as  chalk,  turpentine,  pyrogallic 


342  THE    BACK    OF    THE    HANDS. 

acid,  etc.  The  lesions  are  always  polymorphous  and  include  all  the 
elements  of  eczema;  open  miliary  vesicles,  exudation  from  the  sur- 
face of  an  epidermis  deprived  of  its  superficial  horny  layer,  thin 
serous,  papery  crusts ;  also  miliary  staphylococcic  pustules,  which 
may  form  the  major  part  of  the  eruption,  or  be  rare  and  secondary. 
Lastly,  under  the  crusts,  when  the  lesions  are  very  exudative,  is  seen 
the  thin  lilac  coloured  fibrinous  exudation,  which  is  characteristic  of 
the  presence  of  streptococci,  which  can  easily  be  proved  by  cultiva- 
tion (p.  9). 

Treatment  consists  in  suppression  of  the  traumatic  cause  and  the 
application  of  moist  dressings.  After  a  few  days  the  lesions  may 
be  covered  with  zinc  paste,  till  the  cure  is  complete. 

It  must  be  borne  in  mind  that  the  same  traumatisms  do  not  create 
the  same  forms  of  dermatitis  in  everyone,  but  are  reproduced  almost 
constantly  in  the  same  subject.  These  subjects  have  a  skin  orig- 
inally mediocre,  or  for  some  unknown  cause  are  predisposed  to 
eczema.  As  a  rule,  occupational  dermatitis  are  anatomically  true 
eczemas,  artificially  provoked  and  frequently  covered  by  secondarx- 
infections. 


ECZEMA   IN  TRICHOPHYTOID   PATCHES.     DYSHYDROIC 

ECZEMA. 

These  two  names  designate  the  same  clinical  species ;  an  eczema 
of  chronic  and  recurrent  evolution  and  very  rebellious.  It  is  fairly 
common  and  should  be  well  known.  The  primary  element  is  a  large 
vescicle  more  analogous  to  those  of  dyshydrosis  than  to  the  much 
finer  ones  of  eczema  in  other  situations.  These  vesicles  are  as  large 
as  a  grain  of  barley,  clear,  hard  and  tense.  They  are  disseminated 
on  the  back  of  the  hands  and  fingers,  on  the  lateral  surfaces  of  the 
fingers  near  their  roots,  on  the  borders  of  the  hand,  in  the  interval 
between  the  thumb  and  index  finger,  on  the  inner  border  and  back 
of  the  thumb  and  on  the  thenar  eminence,  especially  near  the  wrist. 
These  vesicular  eruptions  may  have  been  provoked  by  some  pro- 
fessional traumatism,  in  dyers,  photographers,  etc.  They  are 
extremely  irritating  and  subinvolutive  and  may  recur  during  several 
months. 

Eventually  the  vesicles  form  more  or  less  circinate  placards,  which 


The  back  of  the  hands. 


343 


gradually  assume  a  ringworm  aspect,  so  marked  as  to  frequently 
lead  to  errors  in  diagnosis.  The  smaller  patches  are  less  tricho- 
phytic  in  appearance,  and  form  incomplete  circles,  the  size  of  a 
shilling,  with  a  young,  incomplete,  red  and  shiny  epidermis.  These 
small  patches  are  bordered  with  budding  vesicles,  some  of  which  are 
open,  exposing  the  red  epidermis  beneath.  The  larger  cyclic  or  poly- 
cyclic  placards  on  the  back  of  the  hand  are  flat  and  uniform  (two 
characters  eliminating  trichophyton),  red  and  shiny.  They  are 
slightly  elevated  and  covered  with  vesicular  erosions  in  different 
stages,  and  circled  with  irregularly  disposed  vesicles,  some  open 
with  a  red  base,  others  entire. 

This  form  of  eczema  may  accompany  a  more  or  less  generalised 
eczema  of  the  body ;  but  more  often  it  occurs  alone  in  the  extremi- 
ties. It  is  more  common  on 
the  hands  than  on  the  feet, 
although  it  may  occur  in  both 
at  the  same  time.  This  ecze- 
ma, with  its  periods  of  resolu- 
tion, fresh  outbreaks  and 
periods  of  quiescence,  may 
last  for  years  if  the  traumatic 
cause  persists,  or  if  it  is  not 
properly  treated,  Moist  dress- 
ings and  protective  pastes 
cause  no  improvement,  and  ni- 
trate of  silver  only  temporary 
amelioration.  Chrysarobin  is 
the  drug  indicated  in  this  case, 
and  this  fact  alone  suffices  to 
give  the  affection  a  distinct 
personality. 

An  ointment  with  2  per  cent 
of  chrysarobin  is  used  at  first, 
with  oxide  of  zinc ;  later  on  it 
may  be  increased  to  3  per 
cent.  In  the  case  of  a  single 
patch,  recurring  in  the  same 
place,  I  have  obtained  a  cure,  \vhich  lasted  for  four  years,  by  punc- 
ture with  the  galvano-cautery. 


Fig.  147.     Dyshydrosls. 
(Hallopeau's   patient.      St.    I.,ouis    Hosp.    Mu- 
seum,  No.   990.) 


344  THE    BACK    OF   THE    HANDS. 


DYSHYDROSIS. 


Dyshydrosis  is  characterised  by  the  appearance  of  a  symmetrical 
eruption  of  round  clear  vesicles,  on  the  back  of  the  hands  and  their 
borders,  causing  much  smarting  and  itching.  This  eruption  may  be 
limited  to  the  borders  of  the  fingers,  but  is  more  often  generalised 
on  the  dorsal  surface  of  both  hands.  It  sometimes  occurs  on  the 
wrists,  fore-arms  and  feet.  It  differs  from  eczema  by  its  absolute 
symmetry,  its  sudden  appearance,  the  size  of  the  vesicles,  their  diffi- 
culty of  rupture,  the  cessation  of  acute  phenomena  in  a  few  days, 
and  in  the  retrogression  of  all  symptoms  in  one  or  three  weeks. 

The  vesicles  resemble  a  grain  of  tapioca  inserted  "between  the 
skin  and  the  flesh,"  they  are  not  easily  ruptured  and  contain  a  clear 
alkaline  liquid,  which  is  not  viscid  like  that  of  eczema.  Sometimes 
the  eruption  is  discrete,  sometimes  confluent ;  in  the  latter  case  it 
resembles  the  artificial  traumatic  eruptions. 

Dyshydrosis  is  more  common  among  the  ephidrotics  (p.  353)  and 
occurs  generally  in  spring  and  summer.  It  is  not  caused  by  reten- 
tion of  sweat  in  the  sweat  canals ;  but  its  true  cause  is  unknown.  It 
may  or  may  not  be  recurrent.  It  always  proceeds  in  the  same  way 
by  acute  attacks,  accompanied  by  functional  symptoms,  terminating 
by  more  or  less  desquamation. 

Treatment  by  emollients  and  protective  pastes  is  purely  sympto- 
matic.   There  is  no  satisfactory  internal  treatment. 


SCABIES. 

The  localisation  of  scabies  to  the  wrists,  hands  and  fingers  on  both 
their  surfaces  is  one  of  its  chief  characteristics.  It  may  occur  in  two 
forms ;  simple  and  pustular,  the  latter  being  more  common  in  the 
child  or  adolescent.  When  scabies  is  of  moderate  intensity  its  pri- 
mary situation  is  in  the  interdigital  spaces,  in  which  place  a  certain 
number  of  vesicles  in  different  stages,  and  scratch  marks  are  found. 
If  the  palmar  surface  of  the  wrist  and  hand  are  examined  similar 
lesions  will  be  found,  and  the  characteristic  burrows. 

The  burrow,  which  often  occurs  on  the  lateral  surface  of  the 
fingers,  resembles  a  short  worm  track  in  wood,  and  forms  a  narrow 
grey  irregular  line  in  the  horny  epidermis,  often  having  a  vesicle  at 


THE    BACK    OF    THE    HANDS. 


345 


its  extremity.  The  presence  of  burrows  is  charactristic,  especially 
on  the  palmar  surface,  where  they  are  most  frequent,  and  where  most 
diseases  resembling  scabies  (except  prurigo)  never  occur. 

In  severe  and  pustular  scabies  diagnosis  is  made  not  only  by  the 
elementary  lesion,  but  by  the  topography  of  these  lesions  united  in 

the  interdigital  spaces, 
around  the  fingers  and 
wrists.  Search  should 
be  made  in  other  locali- 
sations of  scabies;  the 
front  of  the  axilla,  the 
elbow,  the  waist  and 
penis,  etc.  The  head  and 
neck  are  never  affected. 
The  pustular  form  re- 
sults from  inoculation 
with  true  streptococcic 
impetigo  and  with  the 
staphylococcic  pustular 
impetigo,  in  the  burrows 
and  vesicles.  These  re- 
peated inoculations  cause 
a  varied  appearance. 
They  are  carried  every- 
where by  scratching  and 
may  create  ulcerative  le- 
sions (ecthyma).  An 
impetigo  of  the  extremi- 
ties should  always  sug- 
gest scabies. 

The  treatment  of 
scabies  will  be  described 
with  the  general  disease  (p.  537).  Sulphur  ointments  form  the  best 
applications.  According  to  the  degree  of  secondary  infection  the 
pustules  are  scrubbed,  ut  the  process  is  very  painful ;  "scrubbing 
acts  on  these  impetigos  like  a  cataplasm"  {Tenncson).  In  cases 
which  are  very  pustular  the  impetigo  is  treated  first  by  the  usual 
methods   (p.   10). 


Fig.  148, 

tlon. 


Scabies    Polymorphous  symptomatic  erup- 
(Guibout's    patient.       St.    Louis    Hosp. 
Museum,    No.    391.) 


346  THE    BACK    OF   THE    HANDS. 

TRICHOPHYTOSIS. 

It  is  rare  to  see  ringworm  on  the  back  of  the  hands,  except  in 
the  form  of  Kerion  (p.  158).  Kerion  is  a  trichophytosis  of  equine 
origin  in  the  form  of  foUicuhtis,  grouped  in  circular  patches,  and 
has  exactly  the  same  localisation  as  the  nummular  "trichophytoid 
eczema"  described  above. 

Kerion  of  the  back  of  the  hand  may  assume  an  enormous  devel- 
opment, forming  a  patch  two  inches  or  more  in  diameter.  It  is 
always  rounded,  elevated,  with  sloping  edges  and  a  red  surface, 
covered  with  crusts,  or  follicular  pustules.  The  surface,  after 
cleansing  with  moist  dressings  for  two  days,  appears  as  if  riddled 
with  holes,  the  size  of  a  pin's  head ;  the  remains  of  evacuated  pus- 
tules. The  functional  symptoms  are  clight  and  distinguish  it  from 
carbuncle.  The  occupation  of  the  patient  (groom,  saddler,  veterin- 
ary surgeon)  suggests  the  equine  origin. 

Cultures  may  easily  be  obtained,  by  smears  of  pus  from  unbroken 
pustules  on  saccharated  gelose  peptone  (4  per  cent),  in  the  form 
of  rays  "sprinkled  with  plaster"  {Trichophyton  gypseum).  Micro- 
scopic examination  of  the  pus  shows  an  easily  recognisable  myce- 
lium.   Examination  of  the  hairs  is  more  difficult. 

Treatment  consists  more  in  the  application  of  cataplasms  and 
moist  compresses  than  in  antiseptics,  and  the  latter  must  be  very 
dilute.  Tincture  of  iodine  ( 10  per  cent)  applied  daily  leads  to  a 
cure  in  a  fortnight. 

IMPETIGO     CONTAGIOSA. 

Common  impetigo  contagiosa  is  characterised  by  fiat  phlycte- 
nules, generally  broken,  emptied  of  their  contents  and  shrivelled. 
Other  elements  have  lost  their  horny  epidermis,  forming  flat,  oval, 
crusted  exulcerations.  These  elements  are  situated  on  the  back  of 
the  hands  and  fingers  or  around  the  wrist.  They  nearly  always 
accompany  a  more  characteristic  impetigo  of  the  face,  or  a  peri- 
ungual whitlow  (p.  376).  The  elements  do  not  remain  long  in  the 
same  place.  Each  lasts  for  8  or  10  days,  but  the  eruption  may  be 
prolonged  by  the  development  of  fresh  phylctenules.  These  arise  as 
small,  soft  vesicles  which  develop  into  large  phlyctenules,  filled  with 
slightly  turbid  fluid. 


THE    BACK    OF   THE    HANDS.  347 

When  the  eruption  is  particularly  severe  (acute  benign  pemphi- 
gus of  certain  authors),  the  exulcerations  left  by  the  phlyctenules 
may  be  as  large  as  a  sixpence.  They  exude  a  serum  which  forms 
a  thin  crust  on  the  surface  and  is  removed  by  the  least  touch. 

It  is  a  contagious  affection,  especially  in  children,  and  may  become 
epidemic;  in  which  case  it  is  first  inoculated  on  uncovered  regions, 
but  may  in  some  subjects  cause  generalised  but  always  discrete 
eruptions.     For  treatment  see  page  10. 


FURUNCLES.      CARBUNCLE.      FURUNCULAR  ABSCESS. 

Like  all  regions  exposed  to  traumatism,  the  back  of  the  hands  may 
present  furuncles  and  sometimes  carbuncle.  Furuncle  is  generally 
preceded  by  a  follicular  pustule  which  may  remain  undetected,  after 
which  functional  symptoms  develop  in  proportion  to  the  size  of  the 
lesion.  Local  heat,  smarting  and  pain  are  severe;  progressive  red- 
ness follows,  and  the  furuncle  becomes  acuminated,  with  visible 
suppuration  at  the  summit. 

After  3  or  5  days  a  greenish  yellow  necrotic  core  is  expelled  and 
the  symptoms  subside  and  disappear.  When  other  lesions  are  pro- 
duced around  the  first  inflammatory  focus  a  carbuncle  is  produced. 
This  is  seldom  of  great  size,  but  the  pain  and  inflammatory  symp- 
toms are  very  marked.  The  tumour  is  the  size  of  a  small  nut ; 
sometimes  as  large  as  a  small  orange  and  then  gives  rise  to  consid- 
erable oedema  and  lymphangitis. 

Treatment  should  be  at  first  abortive,  by  means  of  the  galvano- 
cautery,  applied  to  the  follicle  which  is  the  centre  of  the  lesion. 
Afterwards  moist  dressings  are  applied.  When  a  carbuncle  appears 
each  "head"  should  be  pierced  deeply  with  the  galvano-cautery,  so 
as  to  open  the  lesion  extensively.  A  peri-furuncular  abscess  gen- 
erally evacuates  itself  by  the  open  follicle.  If  there  is  a  tendency  to 
coalesce  an  incision,  with  drainage  and  antiseptic  dressings,  is 
required. 

MALIGNANT    PUSTULE. 

Malignant  pustule,  or  charbon.  will  be  described  here  because  its 
usual  situation  is  on  the  back  of  the  hands.  It  may  also  occur  on 
the  face  and  always  attacks  the  uncovered  regions.     Inoculation  is 


348  THE    BACK    OF   THE    HANDS. 

more  frequent  among  leather  dressers,  knackers,  veterinary  sur- 
geons and  horn  workers.  The  anthrax  spores  are  known  to  resist 
months  of  dessication,  and  during  the  cutting  up  the  horns  are 
always  soiled  with  the  animal's  blood.  "Alalignant  pustule"  is  not 
a  pustule,  but  a  brownish  red  phlyctenule,  very  pruriginous  and 
soon  broken,  leaving  a  yellow  exulceration.  The  next  day  a  scar 
is  seen  occupying  the  summit  of  a  large  acuminated  tumour  2 
inches  in  diameter  and  of  a  purple  colour.  When  the  pustule  is 
irritated  a  ring  of  vesicles  appears  round  the  scar,  and  the  floor  of 
each  vesicle  forms  a  new  scar.  The  prognosis  is  serious  because 
general  infection  is  imminent.  The  development  is  described  on 
page  595. 

As  a  rule  malignant  pustule  tends  to  spontaneous  cure.  In  the 
3  or  4  days  following  the  appearance  of  the  scar  a  large  sequestrum 
of  connective  tissue  is  formed,  as  large  as  a  nut,  which  is  eliminated 
like  a  gumma.    After  this  the  local  symptoms  improve. 

Antiseptic  treatment,  such  as  injections  of  i  per  cent  carbolic 
acid  round  the  tumour,  appears  to  be  of  doubtful  value.  The  per- 
manent warm  bath  seems  to  be  the  best  application.  Local  scarifica- 
tion may  be  performed  if  the  tumour  enlarges. 

Extensive  removal  of  the  tumour  with  the  galvano-cautery,  and 
also  injections  of  iodine  (liquor  iodi  of  Gram)  in  the  surrounding 
tissues,  have  been  proposed.  Prognosis  depends  on  the  course  of  the 
temperature.  Although  spontaneous  cure  is  the  rule,  the  percentage 
of  deaths  is  considerable. 


BISKRA    BUTTON.       ORIENTAL    BOIL. 

Biskra  button,  Aleppo  boil,  Annamite  ulcer,  etc.,  are  synonymous 
terms  for  what  appears  to  be  the  same  affection.  The  cause  is  evi- 
dently parasitic,  but  unknown. 

The  lesion  forms  a  chronic  ulcer,  the  evolution  of  which  takes  a 
year  to  18  months.  Those  seen  in  Europe  are  always  undergoing 
spontaneous  resolution.  They  are  generally  situated  on  the  hands, 
legs  and  face. 

The  ulcer  has  a  reddish  brown  base  with  hard,  sharply  cut  and 
irregular  edges.  Around  the  ulcer  the  skin  is  mammillated,  resem- 
bling that  of  chronic  dermatoses  of  the  leg,  often  pigmented  and 


THE    BACK    OF    THE    HANDS. 


349 


scaly.    When  the  ulcer  has  healed  it  resembles  a  commencing  tuber- 
culous lupus,  with  its  yellow  tubercles  enclosed  in  the  skin. 

The  various  forms  of  treatment  in  use  in  tropical  countries  where 
Oriental  boil  is  endemic,  do  not  appear  to  be  of  much  value.     In 


Fig.  149.     Biskra    button. 
(Jeanselme's   patient.      Photo,    by    NolrS.) 


FYance  they  are  treated  as  simple  chronic  ulcer  with  ointment  of 
sub-carbonate  of  iron  ( i  in  40)  ;  but  they  also  heal  spontaneously. 


SIMPLE    WARTS. 

Warts  are  common  on  the  back  of  the  fingers  and  hands,  but  rare 
on  the  palmar  surface.  A  wart  forms  a  small,  hard,  irregular 
tumour,  with  a  mammillated  or  villous  surface.  It  is  reinocula- 
ble  in  the  same  subject  and  sometimes  forms  groups  of  several  ele- 
ments which  may  interfere  with  function.  Peri-ungiial  warts  are 
painful.  Warts  are  not  simple  homy  tumours,  for  they  bleed  if 
abraded. 


SS''- 


THE    BACK    OF    THE    HANDS. 


Treatment  consists  in  the  use  of 
caustics.  Fuming  nitric  acid  ap- 
plied drop  by  drop  to  the  top  of 
the  wart  and  continued  till  pain , 
is  felt  is  a  good  method  when  the 
warts  are  not  numerous.  The 
galvano-cautery,  although  more 
painful,  is  preferable  if  the  warts 
are  numerous ;  followed  by  the  ap- 
plication of  chromic  acid  (i  in  5) 
two  or  three  times  a  week.  Flat 
juvenile  wart,  which  simulates 
some  forms  of  nsevi  or  certain 
eruptions  of  lichen  planus,  m.ay 
occasionally  be  seen  on  the  back 
of  the  hand,  as  on  the  face. 
(See  p.   119.) 

PELLAGRA    AND 
PELLAGROID    ERYTHEMA. 


r"ig.  150.  Common  warts.  (Jac- 
quet's  patient.  Photo,  by  Du- 
bray.) 


Pellagra  is  a  disease  of  Spain 
and  Italy  and  is  not  seen  in  France. 
It  is  a  chronic  intoxication  caused  by  the  use  of  diseased  maize  and 
characterised  by  anaemia  and  cachexia,  burning  sensations  in  the 
mouth ;  and  by  a  peculiar  sensibility  of  the  skin,  especially  of  the 
backs  of  the  hands,  to  the  actinic  rays  of  the  spectrum.  Pellagrous 
erythema  would  thus  appear  to  be  a  solar  erythema  occurring  in 
the  subjects  of  intoxication  having  a  sensitive  skin. 

Pellagrous  erythema  hence  only  differs  from  pellagroid  solar  ery- 
thema by  the  intensity  of  the  local  phenomena  which  accompany  it. 
The  back  of  the  hand  is  red,  swollen  and  sensitive ;  the  skin  is  tense 
and  the  horny  epidermis  often  raised  in  bullae  or  phlyctenules  filled 
with  clear,  turbid  or  brownish  serum. 

Pellagroid  solar  erythema  is  quickly  cured  by  the  application  of 
emollients.  It  lasts  for  a  week  or  more.  Pellagrous  erythema  lasts 
longer  because  pellagra  is  a  disease  of  the  poor ;  because  it  is  not 
treated  and  because  the  causes  persist.  In  France  what  is  incor- 
rectly termed  pellagra  includes  pellagroid  erythema  in  intoxicated, 


THF    BACK    OF    THE    HANDS.  351 

broken  down,  and   overworked   subjects  who  have  exposed  their 
hands  to  the  sun. 

OEDEMA  OF  THE  HANDS. 

All  acute  cutaneous  irritation  is  accompanied  by  oedema  of  the 
back  of  the  hands;  solar  erythema,  traumatic  dermatitis,  etc. 
Oedema'  of  the  hands  may  accompany  some  cachexias,  and  in  this 
case  the  lower  limbs  are  always  more  oedematous  than  the  upper. 
The  oedema  may  depend  on  local  affections  of  circulation  of  inflam- 
matory origin;  but  then  the  local  cause  is  evident  and  the  oedema 
only  exists  on  one  side. 

Reflex  and  trophic  oedemas  have  been  observed  in  several  nervous 
diseases ;  tabes,  general  paralysis,  syringo-myelia,  etc.  Hysterical 
oedema  is  the  best  known  of  these.  It  only  occurs  in  confirmed 
neuropathies  and  is  generally  bilateral  and  chronic,  disappearing 
suddenly  after  years.  The  oedema  is  hard  and  colourless ;  the  skin 
retains  the  impression  of  the  fingers  for  several  hours,  and  is  cold  but 
of  normal  colour.  There  is  often  loss  of  power  in  the  limb  and  the 
nails  may  show  dystrophic  stigmata. 

The  treatment  of  oedemas  varies  with  their  cause  too  much  to  be 
considered  here. 

X-RAY    DERMATITIS. 

This  is  now  a  well  known  accident  which  has  affected  all  the  first 
operators  concerned  with  radiotherapy.  These  accidents  are  not 
now  seen  since  the  necessity  of  enclosing  the  tube  in  an  insulating 
metallic  coat  is  understood. 

X-ray  dermatitis  is  an  atrophic  and  telangiectatic  dermatitis  of  the 
hands  and  fingers.  The  skin  is  smooth  and  white,  and  appears  too 
tight  on  the  finger.  The  natural  folds  have  disappeared.  Varicosi- 
ties arise  in  the  atrophic  skin  as  in  the  skin  of  acne  rosacea.  Here 
and  there  a  more  or  less  marked  warty  condition  develops,  usually 
a  benign  epithelioma,  but  one  which  sometimes  necessitates  ampu- 
tation of  one  or  more  fingers. 

The  following  ointment  may  be  used: — 

Chlorate   of  potash 50  centigrammes  gr.  8 

Oxide  of  zinc 5  grammes  gr.  80 

Vaseline 30          "  5i 


Keratodermia 

palmaris P-  353 


THE  PALM  OF  THE  HAND. 

The  palm  of  the  hand  is  a  region  of  which  the  dermatological 
history  is  important,  and  presents  for  consideration  two  congenital 
affections : 

The  one,  ephidrosis,  is  a  functional  disorder,  conA  „  ,  . , 
.      .        ,                   .          ,  ^Ephidrosis  ....  p.  353 

stitutmg   hypersecretion    of  sweat -• 

The  other  is  symmetrical  hyperkeratosis  of  the 

extremities,  which  is  differentiated  by  its  hereditary 

and  congenital  character  from  the  diverse  palmar 

hyperkeratoses  which   we  shall   consider   later  .    . 

I    shall    next    consider    the    palmar    lesions    of']  ^     ,  . 

,..,,,  I  Scabies p.  354 

scabies;   simple   and   pustular J 

.  .  .  and  the  simple  staphylococcic  pustules  ofs  Staphylococcic  pus- 
the   thick   epidermis f     tules p.  355 

.  .  .  and  the  streptococcic  bullcs  of  phlyctenules-^  Streptococcic  phlyc- 
of    the    same    localisation J      tenules p.  355 

Trichophytosis,    which    assumes    a    peculiar    ap-~\ 

,,,,.,,  I  Pahiiar    tnchophy- 

pearance  m  the  palm  of  the  hand,  will  occupy  our  L 

„     ,.  ,  tosis p.  356 

attention  next J 

Syphilis  causes  a  secondary  hyperkcratotic  /'a/'-]  Secondary       Syph- 

ular  eruption  in   the  palm  of  the  hand J      ilides P- 357 

.    .    .   and     tertiary     lesions,     often     of    difficulty  ^      .        ^     ,  ...  , 

^Tertiary  byphihdes  p.  35S 
diagnosis J 

There  is  a  palmar  and  plantar  keratodermia  of^  „  ,  ,  , 

.  .  Palmar    keratoder- 

adults,  having   the  appearance   of  congenital  sym-  L 

.     ,  ,  ...  .  ,  ....         I      '""'^  of  adults  .  .  p.  359 

metrical  keratodermia  but  without  its  chrontcity  .1 

Chronic  arsenic  poisoning  creates  a  palmar  kera-1   . 
,    ,        .         ,.,,.„  ,  ,,        ,  ,       .     1  Arsenical      kerato- 

todermia    which    differs    from    all    others    by    its} 

^.  ,  ,  ,  .      ,  .      .        ,  I      dermia P-  359 

etiology  atid  by  certain  objective  characters  ...    .J 

Palmar  psoriasis,  in  spite  of  its  somewhat  special 
characters,  is  diagnosed  chiefly  by  the  co-existence 
of  a  typical  psoriasis  in  other  regions   .... 

Chronic  palmar  eczema,  which  is  very  hyper-' 
keratotic,  is  ahvays  accompanied  by  eczema  of  the 
fingers   and    the   peri-ungual   region 

Certain     manual     occupations     determine     locaL       . 
keratodermias,   liable    to    certain    complications  .    .J 


-Palmar    psoriasis    p.  360 


Eczema  palmaris  .  p.  360 


THE    PALM    OF    THE    HAND.  353 

/  shall  conclude  by  a  fezv  words  on  local  affec-^ 

Hans   which   are   rarities,   for   example    the   fleshy  I  Botriomycosis   .    .    p.  362 

pedunculated  tujiiour  of  botriomycosis ' 

.    .    .   the  palmar  localisation  of  Darier's  disease  Darier's   disease   .   p.  362 
.    .    .  and  the  contraction  of  the  palmar  aponcu-^  Contraction    of    the 

rosis  which  a  superflcial  examination  may  mistake  [■■palmar     aponeuro- 

for  a  dermato logical  disease J      sis P- 363 


EPHIDROSIS. 

Ephidrosis,  or  hyperidrosis,  is  an  exaggeration  of  the  sudorific 
function.  This  phenomenon  is  not  rare  on  the  palmar  surface  of 
the  hands  and  the  plantar  surface  of  the  feet.  It  varies  in  degree 
from  moistness  of  the  hand  up  to  actual  streaming  of  sweat.  The 
latter  degree  is  most  distressing  for  the  patient. 

The  hands  are  usually  cold  and  affected  with  evident  circulatory 
or  vaso-motor  troubles.  The  patient  often  has  other  local  abnor- 
malities, such  as  spontaneous  sub-luxation  of  the  thumb,  excessive 
extension  of  the  fingers,  etc. 

This  affection  is  almost  without  any  remedy.  All  those  indicated 
are  palliatives :  powdered  tannin ;  powdered  oat-meal ;  oxide  of  zinc 
or  talc,  etc.,  used  together  or  separately.  The  action  of  high  fre- 
quency currents  is  not  proved,  or  at  any  rate  is  not  constant. 

Ephidrosis  may  occur  in  childhood,  but  becomes  increased  with 
age.  It  appears  to  retrogress  in  old  age ;  but,  nevertheless,  remains 
during  nearly  the  whole  of  life,  as  a  constant  trouble  to  the  patient. 
Many  cutaneous  affections  of  the  hand,  such  as  eczema,  often  co- 
exist with  ephidrosis. 


PALMAR    AND    PLANTAR    KERATODERMIA. 

This  is  a  congenital  deformity,  consanguineous  and  hereditary. 
It  is  more  frequent  in  certain  countries  and  villages  where  marriage 
IS  common  between  relatives.  When  it  is  very  pronounced  it  is 
observed  during  the  first  weeks  or  months  of  life ;  when  less  marked 
it  appears  towards  the  4th  or  5th  year. 

The  palmar  surface  of  the  hands  and  fingers  is  covered  with  a 
horny  carapace,  which,  in  marked  cases,  may  attain  the  thickness  of 


354 


THE    PALM    OF    THE    HAND. 


about  a  quarter  of  an  inch.  It  appears  to  consist  of  one  piece  and 
the  folds  of  normal  skin  become  deep  fissures,  dividing  the  mass  like 
a  mosaic. 

This  condition,  with  individual  variations,  improves  in  the  sum- 
mer and  increases  in  the  winter.  During  the  winter  the  fissures  may 
penetrate  the  epidermis  and  bleed.  Prognosis  should  be  guarded, 
in  spite  of  rare  cases  of  improvement  which  have  been  reported. 
The  functional  loss  of  power  may  be  considerable,  but  less  than  in 
palmar  keratodermic  eczema. 


Fig.  151.     Symmetrical    congenital    keratodermia. 
(Besnier's    patient.      St.    L,ouis    Hosp.    Museum,    No.    1173.) 

As  in  ichthyosis,  treatment  must  be  permanent  and  only  leads  to 
temporary  objective  and  functional  improvement.  After  softening 
the  horny  epidermis  by  moist  dressings,  pumice  stone  may  be 
applied.  Even  on  the  hands  maceration  of  epidermic  debris  in  the 
fissures  often  exhales  an  offensive  odour.  This  will  be  mentioned 
with  plantar  ephidrosis  (p.  397). 

SCABIES. 


Scabies  is  one  of  the  rare  diseases  which  affect  the  palm  with 
disseminated  lesions;  and  in  a  moderately  developed  case  it  is  rare 
for  palmar  lesions  to  be  absent.     The  burrows  are  generally  typical, 


THE    PALM    OF    THE    HAND. 


355 


because  occurring  in  a  thick  epidermis  they  are  not  altered  by  acces- 
sory lesions.  These  burrows  are  as  thick  as  the  stroke  of  a  pen, 
irregular  like  worm  tracks  in  wood^  a  fifth  of  an  inch  or  more  in 
length.  Near  one  of  their  extremities  there  is  often  an  acuminate 
vesicle.  The  palmar  lesions  are  never  seen  without  more  marked 
and  more  polymorphous  lesions  on  the  wrists,  the  interdigital 
spaces  and  the  back  of  the  hand. 

Pustular  scabies  (Fig.  148)  is  often  accompanied  by  palmar  pus- 
tulation.  The  vesicle  becomes  infected  and  forms  a  large  staphy- 
lococcic pustule.  A  pustule  on  the  palm  of  the  hand  may  be  purely 
staphylococcic  (Fig.  152),  and  several  pustules  always  signify 
scabies,  and  are  accompanied  by  dorsal  lesions  represented  in  Fig. 
148.     The  treatment  is  considered  on  p.  537. 

STAPHYLOCOCCIC    PUSTULES. 

The  staphylococcic  pustule  of  the  palm  is  rare;  this  region  being 
doubly  protected  against  the  staphylococcus    by    its    thick,    horny 


Tig.  152.     Staphylococcic    pustule    consecutive    to   a   septic    prick 
(Sabouraud's    patient.      Photo,    by    Nolrg.)  J^^ick. 

epidermis,  and  by  the  absence  of  hair  follicles.    When  such  a  pus- 
tule occurs  it  may  also  be  seen  on  the  fingers  and  hands. 

It  forms  at  first  a  round,  flat  phlyctenule  from  a  fifth  to  two- 
23 


3S6  THE    PALM    OF   THE    HAND. 

fifths  of  an  inch  wide,  full  of  yellow  pus,  visible  by  transparency. 
This  lesion,  sometimes  apparently  spontaneous,  is  often  consecutive 
to  a  traumatism,  a  septic  prick  or  splinter,  etc. 

It  may  follow  two  courses ;  the  phlyctenule  may  dry  and  is 
expelled  Dy  the  renewal  of  the  horny  epidermis  underneath  it ;  or 
in  the  middle  of  its  floor  a  deep  hole  may  form ;  a  button-hole  abscess 
forms;  local  reactional  symptoms  occur,  and  sometimes  even  gen- 
eral symptoms.  The  pus  of  the  deep  abscess  may  invade  the  syno- 
vial sheath  of  the  palmaris  muscles.  Some  cases  are  benign,  others 
severe. 

•  If  there  is  delay  in  opening  the  superficial  pustule  a  considerable 
amount  of  pus  may  be  expressed  through  the  narrow  opening  by 
compressing  the  region.  In  this  case  surgical  intervention  is  re- 
quired. 

This  staphylococcic  pustule  at  its  outset  is  only  the  homologue,  in 
a  region  devoid  of  hair  follicles,  of  the  impetigo  of  Bockhart,  the 
deep  sinous  and  consecutive  abscess  of  which  are  represented  by  the 
peri-furuncular  abscess,  modified  by  the  anatomical  structure  of 
the  region. 

STREPTOCOCCIC  BULLAE. 

These  will  be  described  with  the  fingers,  where  they  are  more 
common  (p.  370).  They  have  the  same  appearance  on  the  hands; 
tense  bullae  or  phlyctenules  filled  with  turbid  serum. 

They  may  be  primary  or  secondary  to  scabies;  but  do  not  cause 
well  marked  symptoms. 

The  pustules  should  be  opened  and  cleansed. 

PALMAR  TRICHOPHYTOSIS 

Palmar  trichophytosis  may  occur  by  inoculation  in  situ,  or  by  ex- 
tension from  the  back  of  the  hand.  It  may  occur  in  two  forms ; 
benign  and  severe. 

The  benign  form  originates  from  one  of  the  common  ring- 
worms of  the  scalp  in  children.  It  may  be  seen  in  medical  men, 
hospital  attendants  and  epilators.  It  consists  in  a  desquamation  of 
the  palm  of  the  hand,  with  white  borders,  and  causes  intense  itching. 
It  may  be  cured  by  simply  cleansing  with  soap  and  pumice  stone, 
without  the  application  of  iodine.  The  more  severe  form  is  more 
regularly  circular,  with  a  smooth  desquamated  centre  formed  of 
young  skin.  The  border  of  the  lesion  is  formed  of  horny,  raised 
and  semi-detached  epidermis.    Around  the  lesion  are  closed  vesicles 


TME    PALM    OF   THE   HAND. 


ZS7 


Under  the  horny  epidermis,  visible  by  transparency.  These  are 
very  pruriginous  and  indicate  peripheral  extension  of  the  lesion. 
They  do  not  project  because  they  cannot  raise  the  thick  horny  epi- 
dermis of  the  region. 

In  this  case  also  scrubbing  with  pumice  stone  is  more  useful  than 
antiseptics.  This  should  be  practised  for  a  week  till  all  the  vesicles 
:of  the  lesion  are  opened.  Moist  dressings  assist  in  the  process. 
-When  the  lesion  is  thus  reduced  to  the  level  of  the  skin,  weak  appli- 
cations of  iodine  (i 
per  cent)  complete 
the  cure.  Recur- 
rence usually  occurs 
if  the  cleansing  has 
not  been  complete. 
When  left  to  itself 
the  duration  of  pal- 
m  a  r  trichophytosis 
is  unlimited.  I 
have  seen  one  last 
for  more  than  three 
years. 

SECONDARY 

SYPHILITIC 
ERUPTIONS. 

Secondary  syphi- 
lis, at  the  time  of 
appearance  of  a  gen- 
eral maculo-papular 
or  papular  eruption, 
creates  papules  in 
the  palm  of  the  hand.  As  there  is  no  other  maculo-papular 
eruption  of  the  body  which  causes  similar  lesions  in  the  hand 
the  diagnostic  importance  of  the  palmar  syphilitic  eruption  is  con- 
siderable. 

The  palmar  eruption  differs  according  as  the  eruption  on  the 
body  is  discrete  or  abundant,  and  the  papules  slightly  or  strongly 
developed ;   but   it    is   generally    recognisable    at   first    sight.      The 


Fig.  153.     Palmar    trichophytosis. 

(Fournier's      patient.      St.      Louis      Hosp.      Museum, 

No.     1650.) 


3S8 


THE    PALM    OF   THE   HAND. 


papules  are  of  a  brownish  colour  and  obviously  situated  under 
the  horny  epidermis,  which  is  slightly  raised  over  them.  When 
the  lesions  are  florid  they  are  still  more  apparent,  of  a  characteristic 
copper  colour  and  visibly  raised.  This  eruption  is  slow  in  disappear- 
ing. Later  on  the  horny 
epidermis  exfoliates  over 
each  papule  and  this  trace 
of  the  past  lesion  differs 
so  much  from  that  of  the 
fully  developed  lesion  that 
the  cause  may  not  be 
recognised. 


TERTIARY 
SYPHILITIC  LESIONS. 


Tertiary  syphilis,  psor- 
iasis and  eczema  may 
cause  lesions  of  the  palm 
which  are  impossible  to 
distinguish  from  each 
other.  However,  I  will 
attempt  to  portray  a  true 
clinical  picture  of  each. 

The  tertiary  palmar 
syphilide  is  usually  char- 
acterised (i)  by  hyper- 
keratosis; (2)  exfoliation;  (3)  a  distinct  red  border  on  one 
side.  The  horny  epidermis  is  much  thickened  around  the  lesion, 
and  beyond  the  border  which  represents  the  active  lesion. 
The  exfoliation  is  irregular,  white  and  lamellar.  The  border  is 
formed  of  exfoliated  lamellae,  more  or  less  detached.  The  base  of 
the  lesion  is  not  everywhere  at  the  same  level,  but  somewhat  irregu- 
lar. The  lesion  is  bordered  by  a  red,  scaly  margin ;  sometimes  very 
clear,  but  absent  in  places.  It  is  usually  serpiginous.  In  the  centre 
of  the  lesion  spots  analogous  to  this  border  may  occur,  and  these 
cause  irregvilarities  in  the  surface. 


Fig.  154.     Palmar    psoriasiform    syphilide. 

(Hillairet's  patient.      St.   Louis  Hosp.   Museum, 

No.    54.) 


THE    PALM    OF    THE    HAND.  359 

The  tertiary  syphilide  of  the  palm  is  generally  unilateral,  but 
not  always,  and  every  hyperkeratotic  palmar  lesion  is  not  neces- 
sarily syphilitic  because  it  is  unilateral.  It  is  unnecessary  to  insist 
on  the  importance  in  such  cases  of  retrospective  enquiry  for  former 
syphilitic  lesions. 

The  treatment  of  a  syphilis  in  which  these  lesions  occur  should 
always  be  intense:  by  injections  of  grey  oil,  etc. 


PALMAR  KERATODERMIA  OF  ADULTS. 

The  congenital  palmar  and  plantar  keratodermia  described  above 
(P-  353)  n^^y  develop  in  a  few  months  in  the  adult,  usually  in  an 
attenuated  form.  It  consists  of.  irregular  keratodermic  masses,  not 
of  a  uniform  layer.  Treatment  by  keratolytic  solutions  and  oint- 
ments, and  by  salicylic  plasters  (i  in  20  to  i  in  5)  are  generally 
successful  in  a  few  months.  The  possible  arsenical  origin  must  be 
borne  in  mind. 


ARSENICAL    HYPERKERATOSIS. 

Arsenical  poisoning  gives  rise,  in  the  palmar  region  only,  to  a 
hyperkeratosis   having  a   remarkable   resemblance   to   sclerodermia. 

The  skin  is  waxy  yellow  and  so  thickened  as  to  render  movements 
of  the  fingers  difificult  and  painful.  But  the  hyperkeratosis  is  not 
regular  and  is  generally  covered  with  characteristic  horny  nodules. 

This  hyperkeratosis,  due  to  arsenic,  is  more  common  than  is 
generally  supposed.  It  may  follow  the  absorption  of  a  moderate 
dose  of  arsenic  and  develop  in  a  few  months;  but  more  often  it 
accompanies  a  chronic  intoxication,  the  arsenic  having  been  usually 
taken  therapeutically.  Many  diseases  which  were  treated  internally 
by  arsenic,  at  the  time  when  arsenic  was  the  internal  drug  for  arthri- 
tis, as  iodine  was  for  scrofula,  were  observed  to  be  accompanied  by 
hyperkeratosis,  which  was  due  to  the  arsenic.  Arsenical  hyper- 
keratosis often  develops  after  a  local  desquamative  erythema.  When 
once  established  it  disappears  very  slowly  after  the  arsenic  has  been 
discontinued.     Its  resolution  may  be  hastened  bv  artificial  cleans- 


36o  THE    PALM    OF   THE    HAND. 

ing.    All  palmar  hyperkeratosis  should  be  investigated  with  a  view 
to  the  possibility  of  its  arsenical  origin. 


PALMAR    PSORIASIS. 

Palmar  psoriasis  is  often  difficult  to  distinguish  from  the  psoriasi- 
form palmar  syphilide  just  described,  and  even  from  hyperkeratotic 
eczema.  The  diagnosis  is  easy  when  the  palmar  lesion  occurs  in 
the  course  of  a  typical  psoriasis,  which  is  the  usual  case ;  but  not 
otherwise. 

The  lesions  generally  begin  at  several  points  at  the  same  time,  in 
the  form  of  thick,  hard,  brown,  hyperkeratotic  discs,  which  do  not 
exfoliate  till  later.  When  the  superficial  horny  layer  is  broken  and 
removed  the  subjacent  hyperkeratosis  manifests  itself  by  the  exfolia- 
tion of  a  number  of  superposed  micaceous  lamellae,  which  are  so 
numerous  and  crowded  as  to  appear  compressed  by  a  press.  When 
these  are  removed  they  leave  a  kind  of  round  cup,  limited  by  a 
foliaceous  hyperkeratotic  border,  raised  and  sloping  externally. 
Nearly  always  several  similar  lesions  develop  side  by  side  and  after 
a  time  fuse  together,  forming  an  irregular  lesion  which  continually 
exfoliates.  Diagnosis  is  only  made  with  certainty  by  the  presence 
of  lesions  on  the  body,  the  back  of  the  hand  or  the  nails ;  when  these 
do  not  exist  the  case  is  always  doubtful. 

The  treatment  is  the  same  as  for  psoriasis  in  general,  after  com- 
plete cleansing.  This  must  be  done  with  great  care,  as  the  success 
of  treatment  depends  on  it.  Prolonged  applications  of  soft  soap 
are  followed  by  rubbing  with  pumice  stone  every  da}- ;  after  which 
the  strongest  applications  are  used,  such  as  pyrog^illic,  salicylic  and 
chrysophanic  acids,  and  increased  according  to  the  resistance  of  the 
particular  case. 

Pityriasis  rubra  pilaris  (p.  369)  is  often  accompanied  by  palmar 
hyperkeratosis,  but  these  lesions  never  occur  by  themselves  and 
only  constitute  a  regional  epiphenomenon  in  the  general  disease. 


CHRONIC    PALMAR    ECZEMA. 

Acute  palmar  eczema  is  rare  and  easily  recognised,  apart  from 
the  general  outbreak  of  eczema  in  which  it  appears. 


THE    PALM    OF   THE    HAND. 


361 


Chronic  palmar  eczema  is  also  easy  to  diagnose  when  it  accom- 
panies a  chronic  peri-ungual  or  a  generahsed  eczema,  or  some 

other  lesion  of  undoubted  ecze- 
matous  nature.  But  it  is  not 
always  so.  It  is  not  even  proved 
that  the  palmar  lesions  known 
as  palmar  psoriasis  or  palmar 
eczema  are  always  psoriasis  or 
eczema,  and  that  there  may  not 
be  a  hyperkeratosis  with  exfolia- 
tion limited  to  these  regions 
which  is  neither  eczematous  nor 
psoriasic.  In  any  case  chronic 
palmar  eczema  generally  occu- 
pies the  whole  palm  of  both 
hands,  and  even  the  palmar  sur- 
face of  the  fingers.  It  is  also 
often  continuous  with  dorsal 
lesions  of  the  fingers. 

The  lesion  is  usually  less 
hyperkeratotic  and  raised  than 
in  palmar  psoriasis,  but  in 
every  case  where  palmar  le- 
sions exist  alone  diagnosis  between  psoriasis  and  eczema  appears 
to  me  illusory. 

The  treatment  of  these  two  aflFections  in  this  situation  is  similar 
and  the  prognosis  should  be  guarded,  for  the  lesions  are  chronic, 
difficult  to  treat  and  liable  to  recur. 

The  local  treatment  of  chronic  palmar  eczema  is  that  of  chronic 
eczema,  by  progressive  doses  of  salycilic  acid  and  resorcine,  after 
previous  moist  dressings  and  cleansing  with  pumice  stone. 


Fig.  155.'  Fissured  form  of  palmar  ec- 
zema. (Brocq's  patient.  Photo,  by 
Sottas.) 


CALLUS. 

Certain  manual  occupations,  by  repetition  of  the  same  trauma- 
tism in  the  same  place,  create  callus,  or  local  hyperkeratosis.  These 
occur  at  the  same  place  in  people  of  the  same  occupation  and  serve 
to  diagnose  their  profession.  Thus  shoemakers  have  a  large  callus 
situated  on  the  fold  which  separates  the  thenar  eminence  from  the 
hand,  and  another  on  the  fold  of  flexion  of  the  fingers  on  the  hand. 


Z(i2 


THE    PALM    OF   THE    HAND. 


on  the  ulnar  border  of  the  hand.  The  repeated  friction  which  cre- 
ates the  callus  generally  causes  a  serous  bursa  underneath  it;  and 
this  may  become  inflamed,  with  symptoms  resembling  bunion,  but 

localised  under  the 
callus  itself.  When 
there  is  suppuration 
rapid  incision  is  nec- 
essary to  relieve  the 
pain  caused  by  the 
formation  of  an  ab- 
scess between  inex- 
tensible  tissues.  When 
the  callus  occupies  the 
natural  folds  it  may 
often  lead  to  the  for- 
mation of  a  median 
fissure  with  callous 
borders.  In  this  case, 
after  treatment  with 
soap  and  pumice 
stone,  the  fissure  may 
be  painted  with 
Friar's  balsam. 


BOTRIOMYCOSIS. 

Botriomycosis  is  a 
rare  affection.  It 
forms  on  the  palm  of 
the  hand,  a  small  fun- 
goid tumour,  red  or 
purple,  soft,  exulcer- 
ating,  non-exudative 
and  apparently 
emerging  from  the 
palm.      The    skin    is 


Fig.  156.     Botriomycosis. 

(N^laton's    patient.      St.    Louis    Hosp.    Museum, 

No.     2203.) 


only  attached  to  it  by  a  thin  pedicle. 

The  etiology  of  this  affection  has  been  much  discussed.    It  appears 
that  the  pedunculated  tumour,  characteristic  of  botriomycosis,  is  a 


THE    PALM    OF   THE   HAND.  363 

simple  fungosity  arising  from  a  septic  puncture  and  developed 
round  a  staphylococcic  colony  which  causes  it.  Treatment  consists 
in  simple  excision  and  cauterisation  of  the  pedicle.  The  cure  is 
rapid  and  permanent. 


DARIER'S  DISEASE. 

Lesions  have  been  described  on  the  palm,  but  are  uncommon  in 
a  disease  which  is  itself  rare.  The  hand  is  covered  with  horny 
globes  enclosed  in  the  thickened  epidermis.  Each  globe  is  rather 
larger  than  a  grain  of  barley  and  resembles  a  grain  of  boiled 
tapioca. 

The  treatment  of  this  localisation  should  consist  in  applications  of 
soft  soap  and  pumice  stone,  or  strong  salicylic  ointment ;  followed 
by  compound  oil  of  cade  ointments  (p.  268),  which  give  the  best 
results  in  the  usual  localisations  of  this  disease. 


PALMAR  CONTRACTION. 

Palmar  contraction,  although  not  a  dermatological  disease,  may 
be  mentioned  here.  It  consists  in  progressive  contraction  of  the 
aponeurosis  of  the  palm,  beginning  generally  on  the  ulnar  side. 
It  may  be  felt  under  the  skin  and  cannot  be  mistaken  for  true  scle- 
rodermia. 


THE    FINGERS. 

The  back  of  the  fingers  resembles  the  back  of  the  hand  to  a  great 
extent  in  its  pathological  dermatolog}',  and  the  palmar  surface  has 
the  most  dermatological  homologues  in  the  palm. 

For  this  reason  we  shall  divide  this  chapter  into  two  sub-chapters 
dealing  with  the  dorsal  and  palmar  surfaces  of  the  fingers  respec- 
tively. There  still  remains  the  end  of  the  finger,  in  the  region  of 
the  pulp  and  around  the  nail,  the  dermatological  affections  of  which 
are  distinct  enough  for  a  special  study.  I  shall  conclude  by  a  sub- 
chapter on  the  nails,  which  are  not  the  least  important  regions  in 
dermatology. 


DORSAL    SURFACE    OF    FINGER. 


Chilblains  are  especially  seen  on  the  hack  of  the 
-fingers,  and  as  they  appear  commonly  at  an  early 
age  zije  shall  speak  of  them  first 

After  chilblains,  small,  multiple,  vascular  angi- 
omata  occur  with  concomitant  horny  transforma- 
tion, forming   the  angiokeratoma   of  Mibelli  .... 

Spina    ventosa     is    a    bony    tuberculosis    which"] 
swells  the  whole  finger  and  gives  it  the  form  of 
a    radish 

Anatomical    tubercle   results    from    the   externah 
inoculation  of  tuberculosis -I 

The  fingers,  like  the  hand,  may  present  diffuse 
erythema  pernio,  and  the  macula  of  erythema  multi- 
forme; but  this  affection  is  common  to  them  with 
the  hands  and  we  have  dealt  with  it  sufficiently 
with   that   region 

Eczema  of  the  finger  only  assumes  a  particulars 
citaracter  around  the  nails J 

Dysliidrosis,  in  its  most  intense  forms,  affects' 
equally  the  hands  and  fingers,  but  it  may  be  limited 
to  the  fingers  and  the  interdigital  spaces  and  re- 
semble scabies 


Chilblain p.  365 


Angiokeratoma  .  .  p.  365 


Spina  ventosa  ...  p. 366 

Anatomical     tuber- 
cle   p.  366 

Erythema      pernio. 
Erythema     multi- 
forme ......  p.  367 


Eczema 


P-367 


Dyshidrosis   ....   p.  367 


THE    FINGERS.  365 

Trichophytosis  may  be  limited  to  the  fingers  .    .     Trichophytosis   .   .  p.  368 

Impetigo  contagiosa  may  cause  plyctenules  on  the^  Impetigo     contagio- 

back  of  the  fingers J      sa p.  368 

.    .    .  also  agglomerated  pustular  folliculitis  .    .    Panaris p.  368 

Pityriasis  rubra  pilaris,  although  a  disease  of  the^ 

,    ,  r  ■        ,  .    .  Pityriasis  rubra  pi- 

whole  surface,   may  present  its   characteristic   ele-  L 

mentary  lesion  on  the  back  of  the  fingers  ...   .J 


CHILBLAINS. 

Chilblains  have  a  well  known  predilection  for  the  fingers.  In 
the  first  stage  they  form  red  indurations  which,  when  they  are  mul- 
tiple, render  the  finger  moniliform.  The  finger  is  cold,  red  and 
oedematous  and  becomes  hot  and  burning  at  night.  In  a  more 
accentuated  degree  the  chilblain  ulcerates  superficially.  The  exact 
pathogeny  of  chilblain  is  not  well  known.  Children  are  more  pre- 
disposed to  it,  and  those  adults  who  preserve  the  physique  and  dis- 
eases of  childhood.  Cold,  especially  when  alternating  abruptly  with 
heat,  is  evidently  the  exciting  cause.  The  treatment  is  unsatisfac- 
tory. The  exulcerations  when  dressed  with  glycerole  of  starch 
appear  to  heal  more  quickly,  and  the  use  of  glycerine  for  the  hands 
during  the  night  may  be  useful  during  the  cold  season.  According 
to  tradition,  cod-liver  oil  and  iodine  are  given  internally  (vide  ery- 
thema pernio,  p.  335). 

ANGIOKERATOMA   OF   MIBELLL 

This  singular  and  somewhat  rare  disease  is  characterised  by 
lesions  having  the  appearance  of  small  vascular  nasvi,  slightly  raised 
and  sometimes  warty,  always  multiple,  often  numerous  and  situated 
on  the  back  of  the  fingers  and  hands,  and  sometimes  on  the  scrotum 
and  penis. 

The  lesions  form  small  purple  stars,  composed  of  venous  dilata- 
tions, surrounded  by  a  fine  capillary  network.  Each  of  these  stars 
is  from  3  to  5  millimetres  in  extent.  The  skin  is  thickened  and 
rather  warty  in  appearance. 

These  lesions  are  not  congenital  but  occur  in  children  or  adoles- 
cents, more  commonly  in  young  girls,  in  successive  crops.  They 
appear  to  be  allied  to  erythema  pernio  and  chilblains,  and  often  fol- 


366  THE    FINGERS. 

low  in  their  course.  This  group  of  lesions  has  been  attributed  to 
the  "lymphatic  temperament."  Certain  authors  even  regard  them 
as  toxi-tuberculides.  Concerning  these  controversial  opinions,  it  is 
only  necessary  to  remember  the  clinical  relationship  which  they 
express. 

Each  varicosity  should  be  treated  by  the  galvano-cautery,  which 
leaves  no  trace  and  quickly  cures  the  lesions.  With  electrolysis  the 
results  are  much  slower  and  not  so  perfect. 


SPINA   VENTOSA. 

This  affection  is  usually  regarded  as  belonging  to  the  domain  of 
surgery.  It  is  an  infantile  type  of  disease,  causing  the  finger  to 
assume  the  appearance  of  a  large  radish.  The  lesion  is  sensitive  to 
pressure,  chronic  and  progressive,  lasting  often  for  years  before 
ending  in  abscess,  fistula  and  amputation  of  the  finger;  or,  on  the 
other  hand,  the  progressive  absorption  of  the  diseased  tissues  and 
disappearance  of  the  local  symptoms.  The  restoration  of  movement 
depends  on  the  integrity  of  the  articulations. 

The  lesion  should  be  examined  by  the  X-rays  and  treated  accord- 
ingly. Radiotherapy  and  phototherapy  should  be  the  first  methods 
to  be  tried  in  the  treatment  of  this  affection. 


ANATOMICAL    TUBERCLE. 

Anatomical  tubercle  is  the  initial  chancre  of  tuberculosis  of  exter- 
nal inoculation.  It  may  assume  several  forms.  Sometimes  it  forms 
a  small  warty  or  papillomatous  growth,  slightly  sensitive  to  pres- 
sure, persisting  for  months  with  slowly  progressive  extension  (Fig. 
140).  The  underlying  skin  is  indurated  and  the  growth  is  not 
wholly  superficial.  In  this  form  anatomical  tubercle  is  only  the  first 
degree  of  warty  tuberculosis  of  the  hand  (p.  336). 

In  other  cases  the  growth  forms  a  mammillated  swelling  on  the 
surface  of  the  skin,  of  slow  extension  and  formed  by  two  or  three 
papulo-tubercles  visible  under  the  slightly  hyperkeratotic  skin. 

More  rarely,  in  the  centre  of  this  growth,  a  minute  ulceration  is 
produced  at  the  bottom  of  a  fissure,  which  at  first  conceals  it.  This 
form,  which  is  comparable  to  ulcerative  tuberculosis  of  the  mucous 


THE    FINGERS.  zdl 

membrane  and  tongue,  is  the  most  resistant  and  most  serious  of  the 
three. 

In  these  three  forms  complete  destruction  of  the  growth  and  of 
the  subcutaneous  induration  is  necessary.  This  may  be  done,  under 
an  anaesthetic,  by  the  galvano-cautery,  and  afterwards  dressed  with 
ointment  of  sub-carbonate  of  iron  (i  in  40).  The  cicatrisation 
should  be  watched  carefully  for  a  long  time.  Tuberculous  lymphan- 
gitis and  adenitis  are  rare,  but  they  should  render  the  prognosis 
guarded,  and  require  active  surgical  treatment ;  excision  followed 
by  phototherapy  of  the  cicatrices. 


WARTS. 

Warts,  which  are  very  common  on  the  back  of  the  fingers,  as  on 
the  back  of  the  hand,  have  been  described  with  the  more  frequent 
morbid  types  of  this  region  (p.  340). 


ECZEMA. 

Eczema  of  the  fingers  is  included  in  eczema  of  the  hand.  It  has 
no  peculiarities  in  nature  or  in  treatment,  except  on  the  end  of  the 
finger  and  round  the  nail,  with  which  it  will  be  described  (p.  385). 


DYSHIDROSIS. 

Dyshidrosis  of  the  fingers  may  occur  alone  without  any  affection 
of  the  hands  (Fig.  147)  and  merits  a  special  description. 

Every  year,  by  seasonal  outbreaks  in  the  spring  and  summer, 
more  or  less  marked  crops  of  vesicles,  sometimes  abortive,  arise  on 
the  lateral  parts  of  one  or  more  fingers  "between  the  skin  and  flesh." 
These  vesicles  are  only  opened  by  vigorous  scratching.  They  are 
accompanied  by  a  moderate  amount  of  pruritus  and  burning.  These 
phenomena  occur  in  small  successive  outbreaks,  lasting  one  or  two 
weeks,  sometimes  a  month,  and  disappear  to  return  in  the  following 
year. 

There  is  no  useful  treatment  and  the  prognosis  is  benign.  There 
are  slight  cases  of  dyshidrosis  of  the  hands  described  on  page  000. 


368  THE    FINGERS. 

These  lesions  are  important,  because  they  are  sometimes  mistaken 
for  scabies.  But  scabies  is  never  locaHsed  exclusively  to  this  situa- 
tion and  occurs  on  the  hands,  wrists,  axillae  and  penis,  which  are 
never  affected  by  dyshidrosis.  Moreover,  scabies  is  contagious  and 
dyshidrosis  is  not. 


TRICHOPHYTOSIS. 

Cases  of  trichophytosis,  localised  to  one  or  more  fingers,  are  not 
rare.    They  may  occur  as  follows : — 

(i)  A  single  finger  may  be  affected,  generally  the  ring  finger 
under  the  ring.  A  vesicular  lesion  develops,  which  extending  beyond 
the  dorsal  region  of  the  finger,  encircles  it,  and  develops  underneath. 

(2)  One  finger  may  be  inoculated  from  the  next;  and  several 
contiguous  fingers  may  be  attacked  one  after  the  other. 

(3)  The  lesion  may  develop  at  the  base  of  a  finger  and  extend 
to  the  hand  and  the  interdigital  spaces,  thus  reaching  the  othei 
fingers  and  the  palm.  This  lesion,  which  may  appear  syphiloid  at 
first  sight,  is  always  vesicular  at  its  edges.  The  characteristic  feature 
of  this  lesion  is  that,  in  spite  of  the  form  of  the  fingers  on  which  it 
develops,  it  always  forms  a  perfect  circle. 

Treatment  is  much  easier  on  the  dorsal  surface  than  on  the  palmar 
surface  of  the  fingers  and  hand.  Friction  with  tincture  of  iodine 
(diluted  4  or  5  times  with  alcohol)  cures  it  in  a  week;  but  on  the 
palmar  surface  this  treatment  must  be  preceded  by  cleansing  with 
pumice  stone  so  as  to  destroy  the  horny  epidermis. 


IMPETIGO    CONTAGIOSA. 

The  turbid  phlyctenules  of  impetigo  contagiosa,  generally  open 
and  shrivelled,  accompany  a  whitlow  (p.  376),  or  an  impetigo  of 
the  hand  (p.  346). 


CARBUNCULAR    PANARIS. 

By  this  name  is  designated  a  pustular  folliculitis  of  the  type  of 
impetigo  of  Bockhart,  occupying  all  the  hair  follicles  of  the  back  of 


THE    FINGERS. 


369 


one  phalanx.  It  is  an  agglomeration  of  superficial  furuncles  with 
objective  and  functional  symptoms  which  are  easy  to  conceive  after 
the  definition  of  this  morbid  type.  Treatment  consists  in  dressings 
with  sulphate  of  zinc  (i  per  cent). 


PITYRIASIS    RUBRA    PILARIS. 

This  disease  will  be  described  with  the  general  dermatoses,  along 
with  psoriasis  which  it  resembles  (p.  528),  but  its  characteristic 
points  may  be  mentioned  here.  Whatever  the  form,  degree  of  gen- 
eralisation and  intensity  of  the  symptoms  of  pityriasis  rubra  pilaris, 
it  is  accompanied  by  one  symptom  on  the  back  of  the  fingers  which 
cannot  be  mistaken. 


Fig.  15 «.     Pityriasis    rubra    pilaris. 
(Besnier's    patient.      St.    Louis    Hosp.    Museum,    No.    692.) 

On  the  back  of  each  phalanx  in  the  normal  state  are  hairs,  vary- 
ing in  number  and  development  in  different  subjects.  The  orifices 
of  their  follicles  become  projecting  and  hyperkeratotic  in  pityriasis 
rubra  pilaris.  Each  becomes  a  small  cone,  visible  to  "ihe  eye  and 
sensible  to  the  touch,  so  that  each  phalanx  assumes  the  aspect  of  a 
file  or  a  grater.  This  symptom  occurs  even  in  atypical  forms  of 
the  disease  and  does  not  exist  in  any  other. 


24 


PALMAR    SURFACE    OF    FINGER. 

The  palmar  surface  of  the  finger  has  few  dermatological  locahsa- 
tions  which  are  not  common  to  the  palm  of  the  hand;  but  several 
dermatoses  assume  a  somewhat  special  physiognomy. 


,  Thus  the  development  of  streptococci  under  thel 
horny  epidermis  creates  large  bullce  xvith  peculiar  y 
contents J 

Staphylococcic  pustules,  although  rare  in  this'Y 
region,   often   lead   to  penaris J 

Chronic  eczema  of  the  palmar  surface  of  thc'\ 
finger  has  the  hyperkeratotic  characters  of  the  I 
eczema  of  thickened  horny  epidermis  in  general  .    .J 

.  .  .  And  may  be  associated  with  symmetrical 
keratosis  of  the  extremities,  which  may  also  occur 
without  it 

Warts  of  the  palmar  surface  of  the  fingers  orr, 
peculiar  in  form  and   often  painful J" 

In  concluding  this  chapter  I  shall  say  a  few' 
words  on  trichophytosis  of  the  palmar  surface  of 
the  fingers 

.  .  .  And  of  a  dermatological  rarity,  the  epi- 
thelial cysts  produced  by  inclusion  in  the  dermis 
of  a  detached  particle  of  epidermis  in  a  penetrating 
wound   


Sero-purulent     bul- 
lae    p. 370 

S  t  a  p  h  y  1  ococcic 
pustules  ....  p.  372 

Chronic  eczema  .  p.  372 


Keratodermia  .  .  p.  372 

Warts P-  372 

Trichophytosis   .   p.  373 

Traumatic  cysts  .  p.  373 


SERO-PURULENT   BULLAE. 


These  may  be  situated  on  the  fingers  or  on  the  hands.  On  the 
fingers  they  usually  occur  on  the  last  phalanx  and  may  be  present 
on  several  fingers.  The  lesion  forms  a  large  ampulla  under  the 
horny  epidermis.  This  is  hard,  tense  and  slightly  painful.  When 
opened  it  discharges  turbid  serum,  the  microscopic  examination  of 
which  shows  myriads  of  streptococcic  chains  (Fig.  158).* 

1  This  drawing  was  made  after  a  culture  of  impetigo  in  a  pipette  of 
serum  after  12  hours;  but  it  gives  an  exact  idea  of  the  appearance  shown 
in  direct  immediate  examination  of  the  bullae. 


PALMAR    SURFACE    OF    FINGER.  371 

This  benign  lesion,  owing  to  its  superficial  nature,  is  not  well 
described  in  the  works  on  dermatology,  although  it  is  not  rare.  It 
is  an  element  of  common  impetigo  (see  pp.  7  &  346),  transformed 
by  the  special  conditions  imposed  upon  it  by  the  thick  horny  skin  of 


Fiff.  158.     Sabouraud's    preparation. 
(Drawing    by    Gillet.      Obj.    1-5    Zeizz.    ocul.    compens.    4.) 

the  region,  and  protected  by  this  against  secondary  infections.  These 
streptococcic  bullae  may  co-exist  with  whitlow  (p.  376),  with  com- 
mon impetigo  of  the  face,  or  may  directly  follow  the  accidental  intro- 
duction of  a  splinter  or  thorn,  etc. 

Treatment  consists  in  careful  removal  of  the  envelope  of  the  bullae, 
taking  care  not  to  spread  the  contents  on  the  hands  in  opening  it; 
followed  by  bathing  the  finger  several  times  a  day  in  the  following 
lotion : — 


3  grammes 

gr.3 

2          " 

gr.2 

500 

3i 

Sulphate  of  zinc 

Sulphate  of  copper , 

Camphorated  distilled  water  .    . 

•     Between  these  applications  the  finger  may  be  kept  in  a  moist 
dressing  with  the  same  liquid,  but  not  covered  with  protective, 


372  PALMAR    SURFACE    OF    FINGER. 

STAPHYLOCOCCIC   PUSTULE. 

This  has  been  studied  with  the  lesions  of  the  palm  of  the  hand, 
where  it  is  most  commonly  observed  (p.  355).  It  is  a  round,  flat 
pustule  varying  in  size  and  usually  consecutive  to  a  septic  puncture. 
It  should  be  opened  and  cleaned  as  early  as  possible,  as  it  may 
form  the  origin  of  a  deep  abscess,  which  may  communicate  with  one 
of  the  synovial  sheaths  and  form  an  extensive  whitlow. 

CHRONIC    ECZEMA. 

On  the  palmar  surface  of  the  finger,  as  on  the  palm  of  the  hand, 
chronic  eczema,  either  secondary  or  spontaneous,  often  assumes  a 
hyperkeratotic  and  fissured  form.  The  surface  becomes  thick  and 
scaly,  and  the  folds  of  flexion  cracked.  Fissures  are  produced,  even 
beyond  the  folds  of  flexion.     It  is  an  eczema  of  extreme  chronicity. 

If  there  is  a  traumatic  cause  this  must  be  first  suppressed.  In  all 
cases  where  a  lesion  is  hyperkeratotic,  mechanical  scrubbing  is  neces- 
sary. The  lesions,  after  softening  by  moist  dressings,  may  then  be 
treated  like  chronic  eczemas  (p.  342). 

It  must  be  remembered  that  in  most  of  the  fissured  lesions  glycer- 
ine preparations  are  preferable  to  vaseline  ointments.  After  the 
first  smarting  has  passed  off  they  give  more  relief  than  any  other 
preparations,  and  this  is  an  important  point  in  cases  of  eczema  which 
are  often  very  painful  on  every  movement  of  the  fingers. 

SYMMETRICAL    KERATODERMIA. 

This  congenital,  hereditary  and  consanguineous  hyperkeratosis 
has  been  referred  to  in  studying  palmar  diseases  (p.  353).  It  may 
also  occur  on  the  palmar  surface  of  the  fingers.  The  persistence  of 
the  hyperkeratotic  and  fissured  eczemas  of  this  region  may  possibly 
be  due  to  a  spontaneous  predisposition  to  hyperkeratosis  (p.  359). 

WARTS. 

Warts  on  the  palmar  surface  of  the  finger  present  a  somewhat 
peculiar  symtomatology.     They  are  imbedded  in  the  horny  epider- 


PALMAR    SURFACE    OF    FINGER.  373 

mis,  on  which  they  form  a  blunt  projection,  which  is  painful  to  pres- 
sure, like  a  corn  on  the  sole  of  the  foot. 

This  causes  a  certain  amount  of  functional  weakness  which 
requires  intervention.  Moreover,  warts  in  this  region  perforate  the 
horny  epidermis,  but  do  not  adhere  to  it  and  are  surrounded  by  a 
deep  furrow,  which  may  become  infected. 

Treatment  is  essentially  surgical.  Under  an  anaesthetic  the  wart  is 
completely  destroyed  by  the  galvano-cautery  down  to  the  dermis. 
If  this  is  not  done  deeply  enough  the  wart  will  recur. 

Palmar  warts  must  not  be  confounded  with  the  occupational  callus 
mentioned  above  (p.  361). 


TRICHOPHYTOSIS. 

Trichophytosis  scarcely  ever  begins  on  the  palmar  surface  of  the 
finger,  but  often  invades  it.  The  general  appearance  of  the  lesion 
is  characteristic,  forming  a  perfect  circle  surrounding  the  finger. 

It  is  vesicular  on  the  dorsal  surface  and  appears  to  be  hyperkera- 
totic  on  the  palmar  surface ;  but  it  is  often  vesicular  also  under  the 
thick  horny  epidermis,  which  conceals  the  vesicles.  The  treatment 
by  scrubbing  is  described  on  page  357. 


TRAUMATIC    CYSTS. 

Sub-epidermic  traumatic  cysts  form  a  rare  affection  of  curious 
etiology.  In  certain  occupations  in  which  the  fingers  are  liable  to  be 
penetrated  by  instruments,  epithelial  debris  carried  by  the  tool 
becomes  grafted  in  the  depth  of  the  skin  and  is  organised  in  closed 
cysts,  exactly  similar  to  minute  dermoid  cysts  originating  from 
fcetal  inclusion. 

These  roimd,  semi-transparent,  pearly  cysts  are  often  multiple  on 
the  same  finger,  and  are  always  localised  exclusively  to  the  palmar 
surface. 


THE  TIP  OF  THE  FINGER. 


The  tip  of  the  finger  '.       a  special  dermatological  pathology,  which 
differs  from  that  of  the  l  xse  of  the  finger  or  the  hand. 


Syphilitic  chancre,  so  difficult  to  diagnose  and  so 
often  mistaken,  is  nearly  always  peri-ungual  . 

The  same  with  lupus  of  the  finger,  so  often  mis- 
taken for  chronic  eczema;  and  papillomatous  tuber- 
culosis, which  we  have  already  studied  on  the  back 
of  the  hand  

Whitlow,  impetigo  contagiosa  of  the  nail  bed,' 
streptococcic  phlyctenular  peri-onychosis,  has  the 
same  localisation 

There  is  a  peri-ungual  eczema,  with  special  char-^ 
acters  and  causes,  having  a  peculiar  physionomy  I 
and  treatment J 

And  there  is  a  peri-ungual  psoriasis,  often  dif-^ 
ficult   to   diagnose J 

Other  affections,  such  as  warts,  assume  specials 
characters,  when  they  occur  round  the  nail,  and  L 
require  mention J 

Lastly,  certain  general  affections,  such  as  sclero-^ 
dactylitis,  have  a  primary  localisation  in  the  fingers] 

Certain  affections  present,  at  the  end  of  the 
finger,  localisations  and  manifestations  of  con- 
siderable diagnostic  importance;  for  instance 
leprosy    


r     Syphilitic  chancre  p.  374 

Lupus.     Papillon 
atous    Tubercu- 
losis    p. 375 


Whitlow 


■  P-376 


Peri-ungual    ecze- 
ma   p.  377 

Peri-ungual   psor- 
iasis   p.  379 

Warts p.  380 

Sclerodactylia     .  p.  380 


Mutilating      Pana- 
ris   p.  381 


SYPHILITIC    CHANCRE. 


Syphilitic  chancre  of  the  finger  is  the  most  common  of  occupa- 
tional chancres  (medical  men  and  mid  wives),  and  one  of  the  most 
dangerous  when  it  is  not  recognised  in  time.  It  is  met  with  apart 
from  professional  contamination.  It  is  rarely  seen  at  its  onset,  and 
when  fully  developed  may  resemble  a  whitlow,  a  tuberculous  lesion 
or  a  chronic  eczema.  It  is  generally  situated  at  the  side  or  base  of 
the  nail  and  enlarges  the  finger  considerably,   forming  an  oblong 


THE   TIP    OF   THE   FINGER.  375 

hard  tumour,  from  half  an  inch  to  an  inch  in  length.  Its  surface  is 
red  and  squamous  at  the  edges,  sometimes  slightly  exudative  in 
the  ungual  groove.  There  is  nothing  resembling  the  eroded 
saucer-like  surface,  or  the  hard,  cartilaginous  induration  of  the  usual 
syphilitic  chancre.  Hence  the  principal  characters  of  syphilitic 
chancre  are  wanting  in  this  situation. 

Diagnosis  is  made  by  exclusion:  (i)  from  lateral  ungual  abscess 
by  the  absence  of  painful  symptoms  and  the  long  duration;  (2)1 
from  local  tuberculosis  by  the  time  being  too  short  for  this  to  reach/ 
such  a  development;  (3)  from  ungual  eczema,  which  would  not 
occur  on  a  single  finger  with  this  increase  in  size.  In  these  condi- 
tions the  epitrochlear  gland  should  be  examined;  in  chancre  it  is 
hard,  enlarged  and  characteristic.  The  chancre  is  of  long  duration, 
lasting  for  two  or  three  months  before  becoming  covered  with  epi- 
dermis.    Poly-adenitis  and  roseola  confirm  the  diagnosis. 


PAPILLOMATOUS   TUBERCULOSIS.       LUPUS. 

The  groove  of  the  nail  may  present  two  types  of  local  tuber- 
culosis, which  are  very  different:  papillomatous  tuberculosis  and 
lupus. 

Papillomatous  Tuberculosis.  This  occupies  the  lateral  angle 
of  the  nail  or  its  base.     It  forms  a  rounded  or  oblong  island  of 


Fig.  159.     Vegetating  tuberculosis. 
(Vldal's  patient.      St.   Louis  Hosp.   Museum,   No.   720.) 

"papillomatosis,"  a  slightly  raised,  warty  hyperkeratotic  neoplasm. 
In  the  bed  of  the  nail,  when  this  is  invaded,  the  velvety  structure 
of  the  growth  is  evident.    There  may  be  slight  exudation. 

Peri-ungual  lupus  is  difficult  to  diagnose,  and  is  often  mistaken 
for  chronic  eczema.  However  it  only  affects  a  single  finger,  which 
is  exceptional  in  eczema.  The  nail  emerges  from  thick  fungating 
buds,  painful  to  pressure  and  slightly  exudative  at  the  root  of  the 
nail.    Yellow  tubercles,  persisting  under  glass  pressure,  may  be  seen, 


376  THE   TIP   OF   THE    FINGER. 

especially  at  some  distance  from  the  nail;  but  they  are  more  often 
absent.  Lupus  of  the  nail  with  its  fungosities  resembles  lupus  of  the 
hard  mucous  membranes,  particularly  of  the  gums.     After  some 


Fig.  160.     Peri-ungual   Lupus.      (Brocq's   patient.      Photo,   by   Sottas.) 

time  the  long  duration  and  continued  increase  of  the  lesion  assist  the 
diagnosis. 

The  treatment  of  these  two  lesions  is  surgical.  Under  an  anaes- 
thetic the  fungosities  are  scraped  with  a  curette,  and  afterwards  the 
galvano-cautery  is  applied  to  all  the  invaded  or  doubtful  tissue. 
Radiotherapy  (7  units  H),  or  phototherapy  should  be  tried,  at  any 
rate  after  surgical  treatment. 

WHITLOW.    STREPTOCOCCIC  PHLYCTENULAR  PERIONYXIS. 

In  its  usual  form  whitlow  commences  by  a  grey,  crescent-shaped 
phlyctenule,  surrounding  one  side  of  the  base  of  the  nail.  This 
phlyctenule  is  filled,  not  with  pus,  but  with  turbid^  serum.  If  it  is 
not  broken  it  extends  gradually  round  the  nail  and  may  reach  the 
end  of  the  finger,  and  create  under  the  free  border  of  the  nail  a 
phlyctenule  more  painful  than. the  first,  which  is  usually  not  very 
sensitive.     More  often  it  is  broken  by  scratching  and  suppurates. 

It  is  a  lesion  of  impetigo  contagiosa  and  streptococcic,  as  is  proved 
by  culture  from  the  unbroken  phlyctenule  (p.  7).  It  usually  accom- 
accompanies  impetigo  of  the  face,  the  back  of  the  hands  or  the  serous 
bullae  of  the  regions  with  horny  epidermis  (p.  370). 

The  treatment  is  that  of  all  streptococcic  impetigo,  by  removing 
the  epidermis  and  frequently  applying  the  following  lotion : — 

Sulphate  of  zinc gr.  iii 

Sulphate  of  copper gr.  ii 

Camphorated  water 3i 


THE   TIP   OF   THE   FINGER.  3Jr*f 

PERI-UNGUAL    ECZEMA. 

Peri-ungual  eczema  may  occur  in  three  different  forms: 


Fiff.  161.     Peri-ungual    and    ungual    eczema.      (Brocq's    patient.      Photo,    by    Sottas.) 

(i)   The  nail  and  the  surrounding  skin  are  affected   together: 


Fig.  162.     Hyperkeratotic  palmar  eczema.      (Erocq'.s    patient.      Photo,    by   Sottas.) 

but  the  finger,  the  hand  and  the  body  of  the  patient  are  free  from 


378 


THE   TIP   OF   THE    FINGER. 


eczema.     In  this  case  the  eczema  is  locaHsed  to  the  end  of  the 
finger. 

These  are  generally  cases  of  traumatic,  occupational  eczema,  and 
are  common  in  florists,  photographers,  and  workers  in  cement 
and  sugar. 

In  this  case  the  skin  on  the  back  of  the  finger  is  painful,  red, 
thickened  and  sometimes  exudative,  sometimes  squamous ;  the  horny 
epidermis  is  destroyed  and  fissured.  Treatment  consists  in  sup- 
pression of  the  cause,  and  the  application  of  nitrate  of  silver  (i  in  5) 
and  protective  pastes,  to  the  peri-ungual  furrow. 

(2)  Eczema  of 
the  ends  of  the  fin- 
gers coincides  with 
the  same  affection  of 
the  toes.  At  the  four 
extremities  there  is 
marked  hyperkera- 
tosis, not  only  on 
the  back  of  the  digit, 
but  at  the  end,  and 
under  the  free  bor- 
der of  the  nail, 
which  is  thickened, 
waxy,  often  fissured 
and  painful.  Some- 
times there  is  sym- 
metrical keratoder- 
mia  of  the  extremi- 
ties which  is  com- 
plicated by  eczema- 
tisation.  Most  often  the  cause  of  this  form  of  eczema  and  of  its 
localisation  is  unknown. 

Treatment  is  by  means  of  keratolytic  agents ;  resorcine,  salicylic 
acid  ( I  in  5  or  I  in  4)  ;  paste  of  soft  soap  or  caustic  soda  applied 
with  a  brush;  The  hyperkeratotic  lamellae  are  softened  by  this 
means,  and  the  fissures  are  treated  by  daily  applications  of  Friar's 
balsam.  Usually  preparations  with  a  basis  of  glycerine  are  better 
tolerated  than  those  with  other  excipients.  The  peri-ungual  lesions 
are  treated  in  the  same  way  as  the  preceding  form. 


ngr.  163.     Eczema    of    the    fingers    and    nails. 
(Vldal's  patient.     St.   Louis  Hosp.   Museum,   No.   361.) 


THE   TIP    OF    THE    FINGER.  37O 

(3)  Lastly,  ungual  and  peri-ungual  eczema  may  only  be  a  regional 
episode  in  a  chronic  generalised  eczema,  and  in  this  case  it  requires 
special  treatment  based  on  the  use  of  nitrate  of  silver  and  tar.  Its 
prognosis  is  that  of  the  general  dermatosis  of  which  it  forms  part. 

Oxide  of  zinc 15  grammes     5  iv 

Liquid  tar 4  "  3i 

Ichthyol 2  '"  5  s.s. 

Sweet  oil  of  ahnonds 15  "  3  iv 

Lanoline 30  "  3i 


PERI-UNGUAL    PSORIASIS. 

In  distinction  to  eczema,  psoriasis  rarely  affects  the  skin  of  the 
peri-ungual  region.     The  nail  is  distinctly  diseased,  but  the  skin 


File.  104.     Psoriasis    of    the    nails. 
(Thibierge's   patient.      St.    Louis    Hosp.    Museum,    >;o.    i:;i2.) 

itself  is  not  affected,  except  at  the  root  of  the  nail,  which  gapes  a 
little,  where  the  epidermic  layer  normally  adherent  to  the  lunula  is 
absent. 

But  when  the  skin  of  the  bed  of  the  nail  is  psoriasic  there  is  usually 
generalised  psoriasis;  the  skin  of  the  hands  and  fingers  is  diseased 


3^0  THE    TIP    OF    THE    FINGER. 

as  a  whole  and,  even  in  this  case,  the  skin  is  not  more  affected  round 
the  nail  than  on  the  rest  of  the  finger.  The  contrary  may  occur, 
but  this  is  rare  (Fig.  164). 

PERI-UNGUAL   WARTS. 

Simple  warts  may  accumulate  in  the  lateral  furrow  of  the  nail 
and  insinuate  themselves  under  the  lateral  or  free  border,  causing 
great  pain  on  pressure. 

The  diagnosis  from  papillomatous  tuberculosis  is  generally  made 
by  the  coincidence  of  other  warts  on  the  fingers  or  hand.  More- 
over, the  warts  are  unaccompanied  by  any  inflammatory  symptom. 

They  may  be  destroyed  by  chromic  acid  or  other  caustics ;  but  I 
have  always  been  obliged  to  use  the  galvano-cautery  to  obtain  a 
definite  cure.  Anaesthesia  is  required  in  all  operations  in  this  sensi- 
tive region. 

SCLERODACTYLIA. 

I  have  already  spoken  of  sclerodactylia  (p.  339).  It  is  not  a  dis- 
ease of  the  fingers,  as  its  name  appears  to  indicate,  but  an  affection 


Tig.  165.     Mutilating    Sclerodactylia. 
(Fournier's   patient.      St.    Louis    Hosp.    Museum,    No.    580.) 


THE    TIP    OF    THE    FINGER. 


381 


of  the  whole  skin,  which  will  be  studied  with  the  general  dermatoses 

(p.  615 ).    But  it  commences  on  the  fingers,  extends  to  the  hand,  and 

gradually  to  the  whole  limb. 

It  consists  in  a  thickening  of  the  whole  skin,  at  first  increasing  the 

size  of  the  finger.    The  skin  is  yellow,  waxy  and  translucent.    This 

carapace  then  apparently 
becomes  contracted  and 
the  finger  atrophied ;  and 
while  the  hard  oedema  and 
hypertrophy  reach  the 
hand,  the  fingers  become 
fusiform  and  thin  at  the 
ends,  and  may  lose  their 
terminal  phalanges ;  the 
bones  of  which  may  pro- 
ject, surrounded  by  a  bed 
of  fungosities. 

This  disease,  which  is 
no  doubt  of  trophic  ori- 
gin, but  of  which  the 
mechanism  and  causes  re- 
main obscure,  terminates 
slowly  by  cachexia  and 
death,  usually  by  some  in- 
tercurrent  disease. 


MUTILATING   LEPROSY. 


^-  *^f;**^    Mutilating    Panaris    in    leprosy  q-j^g     multilatiug     formS 

Fig.  167.     Onychorrexis.      (Dubreuilh's   patient.)  ^  o 

of  leprosy  are  common 
(p.  339).  They  most  often  occur  in  tropheneurotic  or  mixed 
leprosy.  The  usual  type  is  the  chronic  panaris  of  Morvan  with 
muscular  atrophy,  tendinous  contractions  and  disorders  of  sensa- 
tion, etc. 

Ulcers  similar  to  perforating  plantar  ulcer  are  produced,  which 
end  in  denudation  of  the  bone  and  loss  of  the  phalanges.  The 
same  phenomena  have  been  described  in  syringo-myelia,  not  of 
leprous  origin. 


THE  NAILS. 


Ungual  malforma- 
tions of  severe 
diseases p.  384 


/  shall  first  explain  the  diverse  changes  of  the^  „  ,.  . 

.,    .  I  Generalities.  .  .     .  p.  383 

nail   in   general J 

The  nails  may  be  absent ;  or  may  maintain,  from'\  „  .    , 

,  .  ...         Congenital  atrophy 

birth  to  death,  a  more  or  less  dystrophic  condition,  I 

„.,,,.,                     ,       ,  and   dystrophy  .  p.  384 

affecting  all  the  nails  or  several  only J 

The  nails  may  become   the  occasion  of  a  well-^ 
knozm    mania;    onychophagia j  Onychophagia  .  .  .  p.  384 

All  the  severe  diseases  of  the  organism  affect  the' 
nutrition  of  the  nails,  as  that  of  the  hairs;  usually 
manifested  by  more  or  less  marked  transverse  fur- 
rows   

Among  the  onychoses  of  this  region,  the  syphilitic-^  Syphilitic  ony- 
onychoses  require  special  mention J      choses P- 385 

.    .    .  also  the  onychoses  of  lepra Lepra p.  385 

Certain  diseases  more  than  others,  because  they 
have  a  cutaneous  determination,  influence  the  form 
of  the  nails  and  cause  changes  in  them;  especially 
eczema  and  psoriasis 

Others  appear  to  act  on  the  nails  by  trophic  af- 
fections, although  this  cause  has  been  much  abused, 
and  remains  hypothetical  in  many  cases,  in  at- 
tempting  to    explain   ill-defined   onychoses   .... 

Among   the   latter   the   ungual  affections  in   alo—t 
pecia    areata    require    special    mention J 

Lastly,  the  nail  may  be  directly  attacked  by  para-~\ 

sites.     There   is  a   favic   onychosis J 

.    an    onchyosis    accompanying    trichophy-^ 
tosis J 

.    .    ,  another     caused     by     the     staphylococcus^ 


Onychoses  of  the 
chief  dermatoses. 
Eczema,  psor- 
iasis     p. 385 

Onychoses  of  the 
chief  nervous 
diseases p.  387 

Alopecic  onycho- 
sis   p.  388 

Favic  onychosis  .  p.  389 

Trichophytic  ony- 
chosis   p.  389 

S  t  a  p  h  y  1  ococcic 
onychosis  ...  p.  390 


aureus,  which  is  accompanied  by  minute  sub-unguall 

abscesses J 

.    .    .  and  another  caused  by   the  streptococcus,-\      Streptococcic  ony- 
which  is  accompanied  by  phlyctenular  perionychosis]         chosis p.  391 

Apart  from  these  different  types  we  must  bear  in  mind  that  many 
ungual  lesions  are  not  yet  classified,  and  that  ungual  lesions,  when 
they  occur  alone  without  concomitant  cutaneous  lesions,  are  too 
often  indistinguishable  among  themselves. 


THE    NAILS. 


383 


GENERALITIES. 


The  nail  does  not  react  differently  to  each  morbid  cause.  We  can 
distinguish  true  onychosis,  where  the  nail  is  affected  alone;  and 

peri  -  onychosis 
i  n  which  the 
periphery  is  at- 
tacked. These 
two  types  often 
co-exist. 

When  the  nail 
only  is  diseased 
it  may  present 
three  or  four 
morbid  types. 

(i)  InPachy- 
onyc hosts 
(Fournier), the 
nail  is  thick- 
e  n  e  d  under 
the  external 
table,  like  the 
pith  of  a  rush. 

(2)  In  Ony- 
c  h  o  r  r  e  x  i  s 
{Dubreuilh) , 
the  nail  ap- 
pears friable 
longitudi  n  a  1- 
Iv. 

(3)  The 
external  table 
may  be  pitted 

by  multiple    holes,  which    may    be  scarcely    visible    or    sufficiently 
marked  to  cause  deformity  of  the  nail. 

(4)  There  may  be  transverse  stricc,  giving  the  nail  an  oyster  shell 
appearance. 

(5)  There  may  be  hoUozving  of  the  external  table  and  of  the 


^ 

^T^*  ^^^^^^^^H 

1 

1 

r 

^^ 

1 

1 

HE'  A 

I^SB^^^*" 

i-..J 

M 

1 

1 

m^ 

/ 

.^^Bb%  '' 

1 

. 

i 

M 

1 

^ 

A 

^m 

\ 

f 

t 

Jt 

;', 

^^k 

^H 

^^^^^^^ 

^^1 

1^1 

k 

m 

Fig.  167.     Onychorrexls.      (Dubreuilh's    patient.) 


384  THE    NAILS. 

substance  of  the  nail;  a  condition  which  is  seen  in  many  of  the 
chief  dermatoses. 

(6)  Lastly,  there  is  onychogriphosis,  or  curvatuie  of  the  hyper- 
trophied  nail  in  the  form  of  a  claw,  which  is  usually  only  an  exag- 
geration of  the  oyster  shell  deformity  mentioned  above. 

From  these  generalities  it  follows  that  the  nature  of  an  onychosis 
is  often  impossible  to  determine  by  itself  and  that  diagnosis  must  be 
made  by  concomitant  cutaneous  lesions ;  or  when  there  is  a  specific 
parasitic  onychosis,  by  microscopic  demonstration  of  the  parasite. 

CONGENITAL,  ATROPHY  AND   DYSTROPHY. 

There  are  dystrophies  of  the  nails  as  of  the  hairs  (vide  Monili- 
thrix,  p  178),  which  are  often  hereditary  and  consanguineous  and 
often  co-exist  with  other  signs  of  degeneration. 

Sometimes  all  the  nails  exist,  but  in  a  pink  membranous  con- 
dition with  little  resistance.  They  resemble  infant's  nails  of  the 
size  of  those  of  an  adult.  At  other  times  there  are  one  or  two 
tranverse  striae  terminating  by  a  brown  stump,  and  grooved- 
longitudinally. 

The  dystroph}^  may  affect  the  nails  of  one  or  two  fingers  only, 
on  one  or  both  hands.     These  deformities  are  irreparable. 

ONYCHOPHAGIA. 

By  this  term  is  meant  the  habit  or  mania,  which  some  children 
and  even  adults  have,  of  biting  the  nails.  This  habit,  which  is 
common  in  its  ordinary  forms,  at  a  certain  age  and  in  a  certain 
degree,  approaches  a  monomania,  and  resembles  the  mania  for 
epilation  (trichotillomania  p.  146  and  180). 

UNGUAL    DEFORMITIES    OF    SEVERE    DISEASES. 

Every  severe  pyrexia,  and  every  disease,  even  transitory,  hav- 
ing caused  severe  disturbance  of  health,  may  mark  a  transverse 
furrow  on  the  nail,  proportional  to  its  duration.  In  certain 
women  child-birth  causes  the  same  marks.  This  striation  forms 
part  of  the  nail  and  grows  with  it  at  the  rate  of  3  millimetres 


THE    NAILS.  385 

(about  %  inch)  a  month  (Heller),  finally  disappearing.  Many 
transverse  striations  seen  on  the  nail  in  severe  dermatoses,  are 
only  an  exaggeration  of  the  above.  To  the  same  type  is  con- 
nected the  hippocratic  nail,  which  is  most  often  connected  with  a 
chronic  pulmonary  afifection,  and  resembles  onychogryphosis. 

SYPHILITIC    ONYCHOSIS. 

Syphilis  may  affect  the  nail  in  different  ways.  Sometimes  a 
secondary  papule  forms  under  the  nail  and  is  visible  through  it; 
and  as  the  keratinisation  of  the  nail  is  disturbed  at  this  point  a 
loss  of  nail  substance  follows,  which  is  displaced  with  the  growth 
of  the  nail  and  eliminated.  A.  Fournier  has  reported  pachyony- 
chosis,  and  Dubreuilh  hyperonychosis  in  which  the  nail  is  thick 
and  hard. 

Ordinary  syphilitic  onychosis  is  a  lesion  of  the  free  border  and 
of  the  root  of  the  nail.  All  or  most  of  the  nails  are  affected,  in 
the  first  year  of  the  disease,  with  a  peri-ungual  lesion,  especially 
marked  at  the  angles  of  the  nail,  which  resembles  at  first  a  whit- 
low. The  nails  are  swollen,  somewhat  red  and  painful  and  pre- 
sent a  kind  of  projecting  fluting  of  brown  horny  matter,  which 
has  the  appearance  of  a  small  abscess.  In  fact  syphilitic  ony- 
chosis may  suppurate;  the  bed  of  the  nail  is  inflamed  and  a  little 
turbid  liquid  may  be  pressed  out ;  but  usually  it  remains  dry  and 
painful  for  two  or  three  months  and  disappears  under  the  in- 
fluence of  treatment. 

LEPRA. 

Onychosis  also  occurs  in  leprosy,  especially  in  the  tubercular 
stage.  The  nail  is  thick,  raised,  rough  and  incompletely  kera- 
tinised.  There  is  also  peri-onychosis,  the  bed  of  the  nail  being 
infiltrated,  brownish  red  and  ulcerated  at  the  base.  The  nail 
may  fall  and  be  replaced  by  an  indolent  ulcer.  At  other  times 
the  nail  crumbles  and  persists  in  the  form  of  a  tubercle,    (Fig. 

I43-) 

ONYCHOSIS    OF    SEVERE    DERMATOSES. 

The  nails  participate  in  the  dyskeratotic  processes  which  certain 
severe  dematoses  present    on  the    body;    for    instance    pemphigus 


386  THE   NAILS. 

foliaceus  (p.  6io) ;  pityriasis  rubra  pilaris  (p.  528)  ;  general  exfoli- 
ating crythrodermia  (p.  549)  ;  and  the  pityriasis  rubra  of  Hebra 

(P-  549). 

But  in  all  these  cases  the  onychosis  is  only  an  epiphenomenon 
of  no  great  importance  in  itself,  but  ma}^  to  a  certain  extent, 
assist  in  the  differentiation  between  two  analogous  morbid  types. 
Therefore  I  shall  not  dwell  upon  them  here,  but  only  describe  in 
the  following  paragraphs,  the  onychosis  of  eczema  and  psoriasis, 
which  are  more  definite  and  of  greater  clinical  importance. 

ECZEMA. 

In  severe  eczema  the  nail  may  be  raised  by  the  exudation  and 
and  fall  at  once.  If  the  process  continues,  the  matrix  does  not 
form  the  normal  nail  substance,  but  the  nail  bed  is  covered  with 
malformed  horny  excrescences  sometimes  raised  by  vesicles 
(Dubreuilh). 

There  is  generally  chronic  perionychosis,  especially  in  local 
traumatic,  or  professional  eczemas.  But  at  the  same  time  the 
nail  is  eroded,  with  a  rough  surface  and  soft  consistence.  It  is 
painful  to  pressure  owing  to  inflammation  of  the  tissues  beneath 
it.  These  ungual  and  peri-ungual  lesions  are  very  obstinate  and 
liable  to  recur. 

The  treatment  of  perionychosis  is  all  that  can  be  done.  The 
nail  becomes  healthy  when  the  matrix  is  cured.  (See  the  treat- 
ment of  streptococcic  perionychosis,  p.  376.) 

PSORIASIS. 

As  in  the  alopecia  nail,  the  psoriasic  nail  may  be  pitted,  "as  if 
used  for  sewing"  {Dubrenilh). 

In  other  cases  psoriasis  commences  by  a  brown  horny  thicken- 
ing under  the  lateral  borders  of  the  nail  or  under  the  free  border, 
which  appears  as  a  yellow  patch.  When  this  lesion  is  scratched 
with  a  needle,  horny  micaceous  debris  is  removed,  leaving  a  lentic- 
ular space.  Dubrenilh  regards  this  lesion  as  typical  and  diag- 
nostic of  psoriasis,  even  without  cutaneous  lesions.  However, 
it  resembles  closely  those  caused  by  streptococcic  infection  under 
the  nail. 


THE    NAILS.  387 

In  other  cases  the  psoriasis  nail  may  lose  the  whole  or  part 

of  the  external  table,  becoming  hollow  and  striated,  or  resembling 

an  oyster  shell,  and  ending  even  in  onychogryphosis.     In  other 

cases  again  progressive  hollowing  leaves  nothing  but  debris. 

Ungual  psoriasis  is  often  unaccompanied  by  peri-onyxis. 
Psoriasis  and  ungual  mycosis  may  be  most  often  localised  to  the 
nail,  but  not  always. 


Fig.  168.     Psoriasis    of    the    nails. 


(Brocq's   patient.      Photo,    by    Sottas.) 


Treatment  is  by  ointments  with  pyrogallic  acid  and  chrysaro- 
bin,  from  i  in  20  to  i  in  10,  applied  every  night  for  several 
months.  The  fingers  must  be  covered  with  a  glove  to  avoid 
chrysophanic  conjunctivitis.     The  results  are  only  moderate. 

ONYCHOSES    OF    NERVOUS    DISEASES. 


Atrophic  and  dystrophic  affections  of  the  nails  have  been  re- 
ported in  tabes,  general  paralysis,  syringomyelia,  nervous  leprosy 
and  even  in  hvsteria. 


388  THE    NAILS 

ALOPECIA   AREATA. 

The  ungual  changes  in  alopecia  areata  are  frequent  and  exist 
in  nearly  all  cases  of  general  alopecia  and  in  half  the  cases  of 
severe  alopecia.  They  may  even  occur  in  benign  alopecia.  They 
occur  in  three  forms : — 

(i)  The  striated  white  nail.  Leuconychia  is  of  frequent  occur- 
ence and  when  only  slightly  marked,  is  quasi-normal.  But  in 
certain  cases  of  general  alopecia,  each  nail  is  striated  deeply,  and 
this  may  persist  as  long  as  the  alopecia. 

(2)  The  pitted  nail  is  riddled  with  spots  the  size  of  the  eye  of  a 
needle,  and  varying  in  depth.  Sometimes  this  lesion  only  occurs 
on  one  nail,  sometimes  on  all ;  occasionally  in  a  single  trans- 
verse band  on  each  nail.  It  is  the  most  common  affection  of 
the  nail  in  alopecia. 

(3)  The  vertically  striated  and  notched  nail.  This  is  the  onychor- 
exis  of  Dubreiiilh.  The  nail  becomes  fissured  longitudinally  and 
rendered  black  by  dust.  At  the  same  time  the  nail  splits  in  its 
depth  and  is  infiltrated  by  air  which  marks  it  with  yellow  fissures, 
seen  by  transparency.  Lastly,  the  free  border  is  broken  at  one  of 
the  vertical  fissures,  so  that  the  nail  broken  at  different  levels 
appears  notched. 


rig.  169.     Onychorrexis    in    se\  ■  1       :!    :     >  ia    areata. 
(Sabouraud's  patient.      Plioto.   by   Xolre.J 

As  a  rule  when  alopecia  areata  affects  the  nails,  it  suggests  that 
its  duration  was  longer  than  the  aspect  on  the  scalp  or  beard 
would  lead  one  to  suppose.  The  mechanism  is  unknown  and  the 
treatment  nil. 


THE    NAILS.  389 

FAVIC    ONYCHOSIS. 

Favic  onychosis  is  always  accompanied  or  preceded  by  favus 
of  the  scalp  or  body.  It  commences  by  yellow  opaque  streaks 
in  the  lateral  or  free  borders  of  the  nail,  which  are  visible  by 
transparency.  Later  on  the  nail  is  affected  in  its  whole  thick- 
ness, and  is  increased  in  size  at  the  expense  of  its  density 
("pachyonyxis" ;  like  rush-pith).  The  external  table  of  the  nail 
is  preserved,  or  only  destroyed  later  on. 

Deep  flaws  are  produced,  at  which  the  external  table  falls  in. 
Later  still  the  nail  only  exists  in  the  form  of  horny  debris. 
This  last  condition  is  rare.  Usually  all  the  nails,  or  most  of 
them,  are  affected  on  both  hands ;  there  is  no  peri-onychosis. 

Diagnosis  is  made,  as  in  nearly  all  forms  of  onychosis,  by  ex- 
amination of  the  lesions  of  the  body  and  scalp,  and  is  confirmed 
by  microscopic  examinations.  In  cases  where  the  lesions  are 
confined  to  the  nails  microscopic  examination  is  sufficient  to 
establish  the  diagnosis  by  demonstrating  the  presence  of  parasitic 
elements. 

Scrapings  of  the  diseased  nail  are  placed  on  a  slide  in  a  drop 
of  caustic  potash  solution,  warmed,  and  examined  under  a 
power  of  300  diameters,  without  staining.  The  parasitic  ele- 
ments consist  of  mycelial  fragments,  each  formed  of  several  cells 
with  double  outline,  placed  end  to  end.  The  objective  differ- 
entiation of  the  elements  of  favus  and  those  of  trichophyton  in 
preparations  made  with  nail  scrapings  is  difficult  even  for  a 
specialist.  The  treatment  is  that  of  onychoses  in  general 
(P-  390)- 

TRICHOPHYTIC    ONYCHOSIS. 

The  trichophytons  which  cause  ungual  lesions  are  not  usually 
those  which  cause  the  common  urban  ringworms.  Thus  in 
Paris  trichophytic  onychosis  is  a  rarity.  It  is  generally  caused  by 
a  trichophyton  probably  of  animal  origin,  having  a  violet  culture, 
and  is  especially  a  rural  form  of  ringworm.  Ungual  trichophytosis 
may  occur  alone,  but  more  commonly  in  association  with  a  ring- 
worm of  the  skin,  beard  (p.  157),  or  scalp. 

This  onychosis  occurs  in  all  the  fingers,  but  occasionally  one  or 


390 


THE    NAILS. 


two  are  exempt.  It  is  a  chronic  affection,  which  may  undergo 
spontaneous  cure,  or  more  often  persist  without  change  for  years. 
It  begins  at  the  free  border  of  the  nail  or  in  the  nail  bed,  often 
avoiding  a  medium  island  in  the  external  table.  The  nail  is 
thickened  like  rush  pith,  eroded  on  the  surface,  sometimes  hol- 
lowed and  reduced  to  a  spongy  and  uneven  surface  soiled  by  dust. 

Microscopic  examina- 
tion is  made  in  the  same 
way  as  in  favic  onychosis. 
The  trichophytic  mycelial 
elements  are  very  similar 
to  those  of  favus,  but  are 
more  regular  and  gen- 
erally form  longer  chains. 
The  treatment  of  my- 
cosic  onychoses,  favus  and 
trichophytosis  is  the  same, 
and  is  medical  or  surgi- 
cal. Medical  treatment 
consists  in  the  application 
of  a  dressing  every  night 
for  six  months  soaked  in 
the  following  lotion  and 
[useum,   covered  with  protective: 

5  centigrammes     gr.  r/20 
I  gramme  gr.  5 

100  grammes  5i 


Fig.  170.     Ungual    trichophytosis. 
(Lailler's    patient.       St.     I^ouis     Hosp.     IV 
No.    1190.) 


Iodine 

Iodide  of  Potassium  . 
Distilled  water  .... 


Surgical  treatment  consists  in  successive  avulsion  of  all  the 
nails,  under  chloroform,  and  dressing  with  tincture  of  iodine 
(10  per  cent). 

STAPHYLOCOCCIC    ONYCHOSIS.     STAPHYLONYCHOSIS. 


This  occurs  in  children  and  adults  and  is  always  due  to  the 
same  cause;  viz.,  inoculation  from  the  saliva  by  biting  the  nails. 

A  minute  staphylococcic  abscess  forms  under  the  angle  of  the 
nail,  painful  for  several   days,  and   containing  a  drop  of  pus, 


THE    NAILS.  391 

Which  dries  up  before  the  growth  of  the  nails  renders  it  visible. 
It  appears  as  a  small  mass  of  horny  concentric  envelopes,  which 
can  be  separated  by  a  needle  with  lamellae.  Microscopic  ex- 
amination shows  a  collection  of  staphylococci  in  the  centre. 

The  nails  become  chronically  infected,  or  the  same  cause  re- 
news their  infection,  and  small  almost  painless  abscesses  form 
under  the  free  border  of  the  nail.  At  their  onset,  firm  pressure 
causes  an  almost  imperceptible  drop  of  liquid  to  exude.  Later 
on  the  lesion  becomes  dry  and  appears  to  be  only  hyperkeratotic. 

Both  cause  and  effect  must  be  suppressed.  The  abscesses  are 
opened  with  a  needle  and  dressed  with  sulphate  of  zinc  and  cop- 
per lotion  (p.  376)  for  several  months. 


STREPTOCOCCIC    ONYCHOSIS.      STREPTONYCHOSIS. 

This  is  more  a  peri-onychosis  than  an  onychosis,  and  the  nail 
is  only  affected  secondarily. 

The  lesion  commences  as  described  on  page  376,  but  sub-ungual 
infection  is  produced  and  the  nail  is  raised  by  a  thin  layer 
of  pus.  The  process  may  be  acute  or  sub-acute.  When  the  in- 
flammatory process  has  ceased,  the  nail  often  becomes  separated  at 
the  sides.     It  falls  off  and  is  replaced. 

For  treatment  see  page  376. 


THE    MALLEOLAR    REGION. 


In    the    malleolar   region    a   single    morbid    type^ 
acquires   a   certain   peculiarity;    tliis   is  prurigo   in 
patches,   which    is   generally   symmetrical   and   ac- 
companied,   or    not,    with    prurigo    or    eczema    in 
patches,  in   other  regions 


Eczema  and  Pruri- 
go     p. 392 


Erythema  multiforme  also  has  a  predilection  for  the  maleoli, 
but  it  is  sufficient  to  mention  this,  as  we  have  studied  elsewhere 
its  objective  characters  (p.  328). 

Purpura,  when  localised,  affects  the  legs  and  only  occurs  on 
the  malleoli  when  it  becomes  generalised. 

Certain  bronze-coloured  cachectic  dermatites,  especially  the  dia- 
betic, which  have  an  elective  localisation  for  the  legs,  occasionally 
affect  the  ankles. 

MALLEOLAR    ECZEMA    AND    PRURIGO. 

In  the  external  and  internal  malleolar  regions,  chronic  ec- 
zema, prurigo  and  prurigo  of  Hehra,  may  form  very  special 
lesions.  As  a  whole  they  form  an  oblong  placard,  with  its  long 
axis  vertical,  only  limited  by  a  marked  grey  pigmentation.  On 
the  surface  occur  vesiculo-papular  lesions,  more  or  less  raised, 
vesicular,  dry,  red  and  excoriated  by  scratching. 

In  cases  of  true  prurigo,  the  lesions  are  obtusely  papular, 
slightly  eroded,  non-vesicvilar  and  non-exudative.  In  eczema 
the  lesions  are  vesicular,  coherent  or  confluent ;  and  converted  by 
scratching  into  a  slightly  infiltrated  placard,  somewhat  raised, 
red,  very  pruriginous  and  slightly  exudative  after  attacks  of 
pruritus. 

The  objective  form  of  these  lesions,  in  my  opinion,  matters 
little  so  long  as  they  show  identical  characteristics. 

They  are  rebellious  to  treatment  and  sometimes  intolerant. 
As  a  rule  strong  reducing  agents ;  chrysarobin  i  in  40,  pyro- 
gallic  acid  i  in  20,  or  nitrate  of  silver  i  in  10,  are  the  most  active. 

Protective  pastes  are  applied  betewen  the  applications. 
Plasters  with  salicylic  or  pyrogalHc  acids  (i  in  10)  may  be  used 
as  reducing  agents.  Zinc  plasters  and  pastes  protect  the  lesions 
from  the  air  and  relieve  itching  (Jacquct). 


THE    DORSUM    OF    THE    FOOT. 

I  shall  only  say  a  few  words  on  erythema  pernio;  chilblains; 
dyshydrosis ;  vesicular  eczema ;  nummular  eczema ;  and  trau- 
matic dermatitis  of  this  region 

In  fact,  all  these  morbid  conditions  have  been  studied  with  the 
hand,  where  they  are  more  commonly  observed  and  more  typical. 


/  shall  only  refer  specially  to  papillomatous  tuher-~\ 

culosis,  which  may  attain  unusual  development  in  l  "^PY'^^^^to^s 

[      tuberculosis 
these   regions 1 

.  .  .  and  lupus,  which  is  often  complicated  with 
tuberculosis  of  the  sub-cutaneous  tissues;  which 
often  occurs  in  a  mutilating  form,  or  may  provoke 
complications  which  are  less  common  in  other  situ- 
ations    


P-394 


-  Lupus p.  395 


ERYTHEMA  PERNIO.     CHILBLAINS. 

On  the  foot,  erythema  pernio  (a  frigore)  in  its  diffuse  or  local- 
ised form  (chilblain)  repeats  exactly  the  clinical  picture  which  we 
have  seen  on  the  hands  (p.  335). 

DYSHYDROSIS. 

Dyshydrosis  with  its  rapid  eruption  of  vesicles,  resembling 
grains  of  tapioca  set  in  the  skin,  is  much  more  common  on  the 
hands  than  on  the  feet,  and  is  never  seen  on  the  feet  without  first 
affecting  the  hands.      This  condition  is  described  on  page  344, 

ECZEMA    WITH    LARGE    VESICLES.       NUMMULAR    ECZEMA. 

Eczema  with  large  scattered  discrete  vesicles  occurs  less  often 
on  the  feet  than  on  the  hands  (p.  342).  Eczema  in  the  form  of 
nummular  placards  is  fairly  common  on  the  foot  and  manifests 
itself  by  regular  or  irregular  rounded  lesions  with  a  petaloid  or 
floral  disposition.     The  placards  are  bordered  with  a  red  margin 


394  THE    DORSUM    OF   THE    FOOT. 

and   covered   with   large   uniform   vesicles,   very   pruriginous,    and 
soon   destroyed   by   scratching.     These   vesicles   are   not   repro- 
duced and  are  replaced  by  a  kind  of  red  obtuse  papulation,  which 
remains  pruriginous  for  some  time. 
For  treatment  see  page  343. 

TRAUMATIC    DERMATITIS. 

Traumatic  dermatites  are  less  common  on  the  feet  than  on  the 
hands.  On  the  lower  limb  artificial  dermatites  arise  from  im- 
proper treatment  of  ulcerative  or  traumatic  lesions  of  the  leg 
(p.  304).  The  dermatites  then  begins  on  the  leg  and  generally 
avoids  the  foot. 

ECZEMA    OF    THE    FOUR    EXTREMITIES. 

After  an  artificial  dermatitis  of  the  hands  and  forearms,  there 
is  often  a  similar  production  of  eczematous  dermatitis  on  the 
lower  extremities  (acrodermatitis).  The  mechanism  of  this  is 
obscure.  The  propagation  to  the  legs  is  then  only  a  part  of  the 
general  dermatosis.      For  treatment  see  page  342. 

PAPILLOMATOUS    TUBERCULOSIS. 

This  forms  a  fungating  tumour  on  the  dorsum  of  the  foot, 
formed  of  a  dense  mass  of  small  cauliflower  fungosities.     This 


Fig:.  171.     Vegetating   tuberculosis. 
(HUlairet's   patient.      St.    Louis    Hosp.    Museum,    No.    685.) 


THE   DORSUM    OF   THE   FOOT. 


395 


tumour  appears  to  result  from  external  local  inoculation,  and 
varies  in  development  in  different  cases.  It  is  accompanied  by 
a  few  painful  symptoms,  never  retrogresses,  but  progresses  slow- 

ly-         _     _ 

In  distinction  to  lupus  and  deep  forms  of  tubercle  it  is  easily 
curable  by  scraping  with  a  sharp  spoon,  followed  by  simple 
aseptic  dressings.  The  cure  is  rapid  and  often  complete.  If  the 
lesion  recurs  in  the  cicatrix  the  galvano-cautery  should  be 
applied. 

LUPUS.     DEEP   TUBERCULOSIS.     COMPLICATIONS. 

Lupus  of  the  foot  is  not  so  rare  as  might  be  supposed.  It  generally 
begins  on  the  dorsal  surface  and  near  the  roots  of  the  toes.    It  has 


Fig.  173.     Ulcerative  lupus  of  the  toes,  with  erysipelas  and  elephantiasis.     Pseudo- 

ichthyotic    post-elephantiasic    keratinisation. 

(Vidal's  patient.     St.   L,oui.s  Hosp.   Museum,   No.   674.) 


at  first  the  usual  characters  of  intra-cutaneous  and  non-ulcerative 
lupus  (p.  2o),  but  the  sub-cutaneous  tissue  generally  becomes 
affected  and  filled  with  fungosities.     The  surface  ulcerates  and  the 


396  THE    DORSUM    OF   THE    FOOT. 

lupus  becomes  mutilating,  and  may  cause  loss  of  one  or  more  toes. 
Tubercle  of  the  bone  may  continue  the  process  and  lead  to  amputa- 
tion of  the  extremity. 

In  the  lower  classes  these  lesions  are  always  badly  cared  for,  and 
become  secondarily  infected.  Local  recurrent  erysipelas  is  pro- 
duced, and  afterwards  a  progressive  elephantiasis  of  the  lower  limb, 
with  epidermic  papillomatous  h}pertrophy  and  pachydermia.  The 
local  febrile  and  erythematous  attacks  are  not  due  to  the  initial  dis- 
ease, but  are  superposed  on  it. 

The  treatment  of  lupus  of  the  foot  does  not  differ  from  that  of 
lupus  in  other  situations  (p.  20),  nor  that  of  sub-cutaneous  or 
osseous  tuberculosis  from  that  of  the  same  clinical  types,  in  whatever 
region  they  are  met  wdth.    The  latter  belong  to  the  surgeon. 

The  erysipelatous  complications  should  be  treated  by  moist  dress- 
ings. Local  antiseptics  are  required  to  prevent  recurrence,  which  is 
the  rule  and  leads  to  elephantiasis. 


THE  PLANTAR  SURFACE  OF  THE  FOOT. 

This  chapter,  like  the  others  which  concern  the  foot,  will  be  very 
short,  because  most  of  the  affections  of  which  it  treats  are  analogous 
to,  or  identical  with,  the  same  affections  of  the  palmar  region 
(p.  352). 


leformities^ 

I      Ephidrosis  ....  p.  397 


■  /  shall  first  consider   the   functional  deformities 

of  the  skin,  such  as  sweating  feet 

.   .    .   and    the    anatomical    deformities    such    as^ 

L  Keratodermia  ...  p.  398 
symmetrical   keratodermia J 

/  shall   next  study    the  parasitic   affections;    thc] 

....  Streptococcic  bul- 

bullce   of   streptococcic    infection,    contemporaneous  i 

.,,     .    ^  ,.  ,,  I         lae p.  399 

zvith    impetigo    or    ecthyma j 

,    .    .   and    the    plantar    hypcrkeratotic    and    cx--^     _  .  ,      , 

L    Trichophytosis    .    p.  399 
foliating    trichophytoses J 

Accidental  keratodermia  zvill  next  be  considered,-)  Corns,        Bunions, 

with  plantar  corns,  bunions  and  callus J         Callus p.  4(X) 

.    .    .   and   hypcrkeratotic   plantar   eczema,    often']     ^^        , 

Hypcrkeratotic  ec- 
contemporaneous    with    a    similar    eczema    of    the  L 

I         zema p.  400 

hands J 

.    .    .   and  eczema  in  patches,  of  the  plantar  arch-       Eczema      of      the 

often  trichophytoid  or  syphiloid  in  appearance  .    .j      plantar  arch    .    .  p.  401 

.    .    .  and  plantar  psoriasis,  indent ical  zvith  pal--.     _       .     . 

.     .  1      Psoriasis  ....  p.  402 

mar  psoriasis j 

Syphilis    will    come    next    with    its    secondary!  Syphilis.      Tertiary 

lesions;    but    especially    zvith    serpiginous    tertiary  I        serpiginous 

lesions,  often  of  doubtful  diagnosis J  syphilide  .    .    .  p.  402 

After  this  I  shall  study  chronic  trophic  plantar^      „     .        . 

I      Perforating  ulcer  p.  402 
ulcers,   called   perforating J 

/  shall  conclude  by  a  fezv  zvords  on  the  special!     , ,    , 

^    Madura  foot  ...  p.  403 
exotic  actinomycosis,  named  Madura  foot  ...    .J 

EPHIDROSIS. 

Ephidrosis  or  hyperidrosis  is  a  common  and  distressing  affection, 
which  consists  essentially  in  hypersecretion  of  sweat.  This  hyperi- 
drosis occurs  on  the  hands  with  much  less  inconvenience ;  but  on  the 


398 


THE    PLANTAR    SURFACE    OF    THE    FOOT. 


feet,  enclosed  in  semi-impermeable  stockings,  with  the  toes  crowded 
together,  the  excreted  fluid  which  bathes  the  macerated  epidermis, 
especially  in  the  folds,  becomes  a  culture  medium,  and  the  foetid 
odour  becomes  intolerable. 

This  infirmity  cannot  be  cured,  but  the  chief  inconvenience  may 
be  suppressed.  Local  hygiene  must  be  strict,  and  daily  foot  baths 
are  a  necessity.  The  plantar  surface  of  the  foot  and  the  interdigital 
spaces  should  be  painted  with  a  solution  of  chromic  acid  i  to  3  per 
cent,  which  causes  almost  total  disappearance  of  the  odour.  Weaker 
doses  of  chromic  acid  have  not  the  same  effect,  and  stronger  doses 
may  set  up  a  traumatic  erythema. 

SYMMETRICAL    HYPERKERATOSIS    OF   THE    EXTREMITIES. 

I  have  described  this  congenital  and  consanguineous  malforn  v 
tion  in  treating  of  the  affections  of  the  palm  of  the  hand,  and  itv. 


'm^Pu. 


Fig.  173.     Symmetrical    Keratodermia    of    the    extremities. 
(Fournier's    patient.      St.    Louis    Hosp.    Museum,    No.    1833.) 


objective  characters  are  so  well  shown  in  the  figure  that  further 
description  is  unnecessary. 

The  characteristic   features  are:   pain,   functional   weakness,   lia- 
bility  to   infection,    sweating,    maceration   and    foetor,    which    such 


THE  PLANTAR  SURFACE  OF  THE  FOOT. 


399 


lesions  invariably  present.  The  lesions  require  strict  cleanliness; 
moist  dressings,  scrubbing  with  pumice  stone;  chromic  acid  lotion 
(2  per  cent),  etc. 

STREPTOCOCCIC   BULLAE. 


These  bullae  are  as  large  as  the  phalanx  of  a  finger,  single  or  mul- 
tiple, filled  with  clear  or  slightly  turbid  serum,  painful  on  pressure 

and  on  walking,  and  usu- 
ally occur  in  the  course 
of  an  impetigo  or  ecthy- 
ma of  the  body  (p.  370). 
They  must  not  be  con- 
founded with  the  simple 
blisters  due  to  prolonged 
walking. 

TRICHOPHYTOSIS. 

Plantar  trichophytosis 
is  not  common.  Never- 
theless D  j  e II  a  I e  d  din 
Mouktar  has  shown  that 
several  reputed  eczema- 
tous  lesions  were  really 
trichophytic.  They  near- 
ly always  have  the  same 
appearance  and  consist 
of  circular  lesions,  distinct 
or  fused,  situated  under 
the  heel  or  the  front  of 
the  foot.  These  lesions 
are  exfoliated  in  the  cen- 
tre   and    bounded    by    a 

thick  collar  of  raised  horny  epidermis,  in  the  deep,  dry,  micaceous, 

dehiscent   squames  of  which  is   found  the  mycelium,   in   sufficient 

quantity  for  microscopic  examination. 

Under  the  circumferential  collar  of  raised  horny  epidermis  are 

formed  deep  vesicles,  which  dry  up  before  reaching  the  level  of  the 


Fig.  174.     Plantar    trichophytosis. 

(Besnier's    patient.      St.     Louis    Hosp.     Museum, 

No.    1657.) 


400 
skin 


THE    PLANTAR    SURFACE    OF    THE    FOOT. 


When  they  exfoliate  they  are  nothing  more  than  dry  vesicles 
or  spaces  betwen  the  laminated  hyperkeratotic  squames. 

Treatment  consists  in  scrubbing  with  pumice  and  painting  with 
tincture  of  iodine  (30  parts  in  70  of  alcohol). 


CORNS.     BUNIONS. 

Corns  only  occur  on  the  plantar  surface  of  the  foot.  Under  the 
front  of  the  foot  they  are  large  and  flat,  and  sometimes  complicated 
by  a  very  painful  semi-circumferential  fissure. 

The  best  treatment  is  extirpation  by  the  knife,  after  softening  in 
a  prolonged  bath.  The  decortication  should  be  carried  out  as  far  as 
possible,  and  when  the  level  of  the  epidermis  is  reached,  the  abraded 

surface  should  be  touched  with 
a  crayon  of  nitrate  of  silver, 
and  Friars'  balsam  applied  to  the 
fissure. 

Bunions  are  bony  deformities 
of  chronic  rheumatism  and  re- 
quire no  local  treatment.  Fric- 
tion of  the  shoe  may  cause  the 
formation  of  an  artificial  bursa, 
which  may  become  hygroma. 
The  treatment  of  this  complica- 
tion is  surgical. 


HYPERKERATOTIC    AND 
FISSURED    ECZEMA. 

Chronic  eczema  of  the  foot 
often  assumes  the  hyperkeratotic 
and  fissured  form  indicated  in 
the  accompanying  figure,  espe- 
cially on  the  front  of  the  foot, 
the  heel  and  toes. 
The  squames  are  thick,  hard  and  horny ;  painful  to  pressure 
because   they  cover  an   inflamed   skin;   separated  and   divided  by 


Fig,  175.     Chronic     Eczema    of     the     sole 
of   the   foot. 


THE  PLANTAR  SURFACE  OF  THE  FOOT.      401 

innumerable  fissures,   still   more  painful  because  they   may  pene- 
trate deeply  in  the  inflamed  skin. 

This  form  of  eczema  is  rebellious  and  difficult  to  treat.  As 
in  all  hyperkeratotic  disease,  the  first  treatment  consists  in  scrub- 
bing with  pumice,  after  dressings  with  boiled  water  containing 
10  per  cent  salicylic  acid.  When  the  lesions  are  reduced  to  the 
level  of  the  skin  they  are  treated  as  chronic  eczema  in  general 

(p.  343)- 

Dressings  with  glycerole  of  starch,  mixed  with  saponified  oil 
of  cade,  often  give  excellent  results. 


ECZEMA  OF  THE  PLANTAR  ARCH. 

There  occurs  in  these  regions,  as  the  name  indicates,  an  eczema 
W'ith  circinate  lesions,  very  similar  to  the  nummular  eczema  of  the 
back  of  the  hands  (p.  342). 

Under  the  hyperkeratotic  debris,  the  removal  of  which  is  painful, 
is  found  a  circinate,  or  polycircinate  lesion,  bordered  by  red  seg- 
ments of  circles,  vesicular  in  places.  This  lesion,  which  has  some 
resemblance  to  trichophytic  lesions,  and  especially  to  tertiary  serpigi- 
nous syphilis  of  the  same  situation,  is  very  painful,  pruriginous 
and  slightly  exudative.  It  is  often  accompanied  by  dry,  papulo- 
vesicular eczematous  patches  on  the  internal  surface  of  the  malleolus 
and  this  detail  confirms  the  diagnosis.  This  dry  papulo-vesicular, 
malleolar  eczema  is  objectively  an  intermediate  form  between  eczema 
and  the  prurigos. 

Treatment  consists  in  scrubbing  with  pumice  all  the  hyperkera- 
totic lesions,  and  moist  dressings  under  protective.  Afterwards  the 
following  ointment  is  applied — 

Oil   of  cade -.  -. 

/->   •  J       r     •  ^   aa      s  grammes  L  3  iv 

Oxide  of  zmc j  ^  ^  J 

Ichthyol -,  -]    ^. 

Oilofbirch }  -       ^  "  I^''' 

Vaseline 15  **  Siss 

Lanoline 10  "  $i 

A  complete  cure  is  sometimes  difficult  to  obtain.     The  general 
condition  of  the  patient  requires  treatment.    Recurrence  is  frequent, 
but  a  cure  is  generally  obtained  after  a  few  months. 
26 


402  THE    PLANTAR    SURFACE    OF    THE    FOOT. 

PSORIASIS    OF   THE   FOOT. 

Psoriasis  is  never  localised  exclusively  to  the  feet.  It  requires 
the  same  treatment  on  the  feet  as  elsewhere ;  when  on  the  sole  of  the 
foot,  scrubbing  with  pumice,  etc.  For  further  details  and  for  psori- 
asis of  the  nails  see  pp.  360,  379,  386. 

SERPIGINOUS  TERTIARY  SYPHILIS  OF  THE  PLANTAR  ARCH. 

Secondary  syphilis  manifests  itself  on  the  feet  in  the  same  way  as 
on  the  hands  (p.  357). 

Serpiginous  tertiary  syphilis  appears  to  have  some  predilection  for 
the  plantar  arch  and  the  internal  surface  of  the  foot.  Its  appearance 
is  then  very  similar  to  that  shown  in  Fig.  113  (p.  249),  which  repre- 
sents a  serpiginous  syphilide  of  the  neck. 

It  forms  a  red  polycyclic  border,  narrower  than  a  finger,  covered 
with  striated  adherent  squames ;  the  whole  lesion  enclosed  in  this 
border  is  red,  infiltrated  or  hyperkeratotic.  - 

These  lesions  are  sometimes  sensitive  on  w^alking;  and  even  pru- 
riginous,  like  all  hyperkeratotic  lesions.  They  resemble  hyperkera- 
totic eczema  of  the  same  situation ;  but  the  latter  itches  more  and  its 
border  is  less  clear,  and  it  is  accompanied  by  pruriginous  lesions  in 
irregular  patches  in  other  places,  especially  on  the  two  sides  of  the 
malleoli. 

All  corroborative  evidence  of  syphilis  must  be  carefully  searched 
for.  Treatment  locally  is  the  same  as  for  palmar  syphilis  (p.  358). 
For  general  treatment  of  syphilis  see  page  650. 

PERFORATING    ULCER. 

This  term  is  applied  to  spontaneous  or  traumatic  ulcers,  of  chronic 
evolution,  consecutive  to  peripheral  neuritis  or  local  nervous  disor- 
ders of  central  origin ;  tabes,  lepra,  syringo-myelia,  myelitis. 

The  ulcer  is  produced  at  the  points  subject  to  friction,  generally 
under  the  front  of  the  foot ;  it  may  be  single  or  multiple.  At  first  it 
is  often  taken  for  a  severe  corn,  and  is  often  traumatic  in  origin ; 
after  the  prick  of  a  nail,  a  piece  of  glass,  etc. ;  but  the  wound  does 


THE  PLANTAR  SURFACE  OF  THE  FOOT.      403 

not  heal.  The  ulcer,  when  fully  developed,  is  round  or  oval,  more 
or  less  deep,  with  a  fungating  base  and  raised  hyperkeratotic  edges. 
There  is  usually  complete  anaesthesia  and  the  sore  is  very  fcetid. 

Local  treatment  should  be  cautious,  as  the  active  methods  only 
cause  extension  of  the  ulcer.    Sub-carbonate  of  iron  ointment  (i  in 


Fig.  176.     Perforating    ulcer    in    a    tabetic.     (Jeanselme's  patient.     Photo,    by  Noir4.) 

40),  or  tannoform  are  useful.  This  should  be  covered  with  diachy- 
lon plaster  and  renewed  daily.  The  causal  disease  must  also  be 
treated. 

MADURA  FOOT. 

This  disease,  like  all  exotic  diseases,  will  be  dealt  with  very  briefly. 
It  is  an  actinomycosis  of  the  foot,  probably  of  external  origin,  fairly 
common   among  the   natives   of  the  isles   of   Sunda,   and   even   in 


404      THE  PLANTAR  SURFACE  OF  THE  FOOT. 

Europeans  who  live  there.  The  actinomycosis  is  due  to  a  strepto- 
thrix,  a  near  relative  of  the  Actinomyces  Bovts  (p.  248),  but  distinct 
from  it.  The  disease  is  characterised  by  swelling-  of  the  foot  and  the 
development,  especially  on  the  plantar  surface,  of  a  tumour  of  wooden 
consistence,  formed  of  distinct  nodes  juxtaposed  in  a  hard  oedema. 
These  nodosities  tend  to  spontaneous  ulceration  like  those  of  actino- 
mycosis. The  course  of  the  disease  is  chronic  and  progressive,  and 
the  treatment  entirely  surgical ;  but  before  resorting  to  this  the 
action  of  large  doses  of  iodide  of  potassium  should  be  tried. 


THE    TOES. 

This  chapter  will  be  curtailed  in  regard  to  all  that  I  have  written 
concerning  the  dermatological  pathology  of  the  fingers,  which 
naturally  resembles,  in  many  respects,  that  of  the  toes. 

Secondary     syphilis     often,    causes     interdigitaH  „ 

.      Cutaneous    mucous 
mucous  patches  which  may  give  rise  to  errors  m  V 

patches    .    .    .   .   p. 405 
diagnosis J 

Intertrigo,   due   to   ephidrosis,   has,   in   the   foot,-\  _  .       ^. 

Llntertngo  Fissures  p.  406 
special  symptoms  and  treatment J 

Corns  are   often  present   on   the   toes Corns p.  406 

Papillomatous   lesions   on   the   toes   may  require~\  Papillomatous 

surgical   treatment J      lesions p.  406 

Chilblains  and  angiokeratoma  resemble  those  of-^  Chilblain       Angio- 

the   hand J      keratoma  ....  p.  407 

For  lupus  the  reader  is  referred  to  the  paragraph! 

,     ,      ,  ^Lupus p.  407 

on  lupus  of  the  foot J 

Retraction  of  the   toes,  in   the  form   of  a  claw,^ 

,         ,.•■,■  I  Retraction  of  toes  p.  407 

accompanies  several   cachetic   diseases J 

Gangrene  of  the  toes  is  rare,  but  may  arise  from 

diverse  causes  


^  Gangrene p.  408 


INTERTRIGINOUS   CUTANEOUS    MUCOUS   PATCHES. 

At  the  time  of  the  secondary  syphilitic  eruption  of  papules  and 
mucous  patches,  especially  when  the  syphilis  is  rather  severe,  there 
occur  between  and  underneath  the  toes,  exulcerating  syphilides, 
very  similar  to  the  cutaneous  mucous  patches  of  intertriginous 
regions. 

These  lesions  resemble  broken  blisters  of  the  palm,  caused  by 
excessive  and  unaccustomed  manual  labour.  They  are  at  first  phlyc- 
tenular, but  soon  become  exulcerative.  They  are  situated  in  all 
the  sub-digital  and  interdigital  folds;  they  may  be  discrete  or  con- 
fluent, are  nearly  always  laminated,  and  exhale  a  foetid  odour. 

The  physician  who  is  not  familiar  with  the  lesions  of  syphilis  may 
mistake  them  for  a  simple  or  impetiginous  intertrigo,  an  ecthyma 
or  eczema.     In  doubtful  cases  they  must  be  always  borne  in  mind ; 


4o6 


THE   TOES. 


but  they  never  exist  alone,  and  signs  of  recent  syphilis  are  easily 
found  at  this  period.  Local  treatment  consists  in  strict  cleanliness 
followed  by  cauterisation  by  nitrate  of  silver.  The  general  treat- 
ment is  that  of  secondary  syphilis  (p.  650). 

INTERTRIGO.     FISSURES. 

Intertrigo  of  the  toes  is  usually  the  result  of  ephidrosis  (p.  ). 
The  interdigital  folds  are  moist,  especially  between  the  4th  and  5th 
toes.  In  true  ephidrosis  the  sub-digital  folds  are  intertriginous. 
There  is  itching  and  smarting.  Scratching  removes  macerated  epi- 
thelial debris,  and  the  appearance  of  the  epidermis  is  pearly  white, 
shining,  moist  and  often  fissured. 

Treatment  of  plantar  ephidrosis  by  daily  painting  with  2  per  cent 
chromic  acid  should  never  be  neglected ;  but  I  have  had  better 
results  with  local  friction  with  i  per  cent  permanganate  of  potash, 
the  fissures  being  protected  by  Friars'  balsam.  Afterwards  the  toes 
are  separated  by  wool  powdered  with  oxide  of  zinc  or  tannoform. 


CORNS. 

Everyone  knows  these  lesions.  Corns  are  local  foci  of  keratoder- 
mia,  sometimes  having  a  raised  centre,  which  is  enclosed  in  the  sub- 
jacent epidermis,  and  visible  by  transparency  in  the  middle  of  the 
keratoma,  which  it  centres  like  an  umbilicus.  Treatment  is  prefera- 
bly by  excision 
w^ith  the  bistoury, 
after  a  prolonged 
bath.  For  the 
"partridge  eye," 
after  cutting  with 
the  bistoury,  the 
central  cone  should 
be  removed  by  a 
fine  circular  cu- 
rette. After  these 
small  operations  a 
crayon  of  nitrate 
of  silver  should  be 
applied.  Keratomas 
treated  in  this  way   are  not  reproduced  for  some  time.     If  these 


rig.  177.     Ulcerative    Lupus.      Elephantiasis    censecutive 

to     successive     attacks     of    erysipelas. 
(Vidal's   patient.      St.    Louis   Hosp.    Museum,    No.    674.) 


THE   TOES.  407 

lesions  are  present  in  considerable  numbers  the  patient  should  be 
advised  to  wear  alternate  stockings  of  different  kinds, 

WARTS.    PAPILLOMATA. 

I  have  twice  observed  a  slightly  raised  papillomatous  lesion  cov- 
ering the  little  toe  and  the  fourth ;  this  did  not  appear  to  be  tuber- 
culous, but  a  flat  wart  of  rapid  and  progressive  development. 
After  different  kinds  of  ineffectual  treatment  the  lesion  was  suc- 
cessfully excised. 

CHILBLAINS.      ANGIOKERATOMA. 

Chilblains  occur  on  the  toes  as  on  the  fingers  (p.  365).  The 
angiokeratoma  of  Mibelli  may  also  occur  on  the  toes  and  requires 
the  same  treatment  as  on  the  fingers  (p.  365). 

LUPUS    OF    THE    TOES. 

This  is  included  with  lupus  of  the  foot,  which  has  been  described 
on  page  395  (vide  Fig.  177). 

CONTRACTION    OF   THE    TOES.    HAMMER-TOE. 

This  is  a  congenital  deformity  occurring  in  many  subjects,  in 
which  the  "hammer-toes"  overlap  each  other.     But  it  is  also  pro- 


ri«.  178.     Onychogryphosis.     Tabetic  foot  with  perforating  ulcer. 
(Jeanselmes   patient.     Photo,   by   Noir6.) 


4o8  THE  TOES. 

duced  in  the  course  of  several  cachectic  diseases ;  especially  in  severe 
nervous  diseases,  such  as  syringo-myelia,  leprosy,  tabes,  sclerosis 
in  patches,  and  progressive  muscular  atrophy.  In  the  case  repre- 
sented in  the  figure  it  occurred  in  tabes. 

These  lesions  are  often  accompanied  by  deformities  of  the  nails 
and  onychogryphosis.  The  treatment  is  purely  orthopoedic  and 
generally  consists  in  the  wearing  of  special  socks. 

GANGRENE    OF   THE   TOES. 

Gangrene  of  the  toes  may  occur  in  chronic  ergotism ;  in  the  course 
of  infectious  diseases;  after  septic  arterial  thrombosis;  in  atheroma 
due  to  endarteritis  obliterans,  and  in  diabetes.  Also,  gangrene  by 
freezing  is  often  seen  in  wounds  on  the  battle  field.  The  treatment 
of  these  cases  belongs  to  the  surgeon  rather  than  to  the  dermatolo- 
gist. 


THE    NAILS. 

The  nails  of  the  toes  may  present  all  the  lesions  which  affect  the 
nails  of  the  hands  (vide  p.  382). 

The  onychoses  of  eczema  and  psoriasis,  and  streptococcic  peri- 
onychosis  (whitlow)  are  identical  on  the  hands  and  feet.  The 
onychoses  of  secondary  syphilis  are  less  common  on  the  feet  than 
on  the  hands,  but  present  the  same  symptoms.  The  onychomycoses 
(favus  and  trichophytosis)  are  rare  on  the  toes,  but  they  are  sel- 
dom looked  for.  I  have  never  seen  staphylococcic  onychosis  of  the 
toes,  which  occurs  on  the  hands  (p.  390). 

On  the  other  hand,  in  onychoses  of  the  foot  the  detachment  of 
the  nails  and  the  production  of  foetid  exudation  under  them  are 
much  more  common.  Treatment  consists  in  avulsion  of  the  nail 
and  local  treatment  of  the  cause  during  regrowth  of  the  nail.  In- 
growing toe  nail  may  require  removal  of  the  whole  lateral  insertion 
of  the  nail.  Onychogryphosis  is  more  common  on  the  feet  than  on 
the  hands,  and  requires  a  brief  mention. 

ONYCHOGRYPHOSIS. 

This  is  not  a  disease,  but  a  symptom.  The  nail  is  hypertrophied, 
claw  shaped,  transversely  striated  like  a  goat's  hoof,  or  like  an  oyster 


Fig.  179.     Onychogryphosis.      (Dubreuilh's  patient.) 


4IO  THE    NAILS. 

shell.  This  deformity  is  especially  common  on  the  great  toe  and  is 
less  marked  on  the  other  toes.  It  may  be  due  to  local  irritation, 
such  as  eczema  or  psoriasis;  but  is  more  often  consecutive  to  local 
traumatism,  or  to  trophic  disorders ;  contraction  of  the  toes,  or  severe 
diseases,  such  as  tabes,  leprosy,  syringo-myelia,  etc. 

The  local  treatment  consists  in  cutting  the  nail  after  softening  by 
moist  dressings.    In  simple  traumatic  cases  the  nail  may  be  removed. 


THE    GLANS   AND    PREPUCE. 

The  region  of  the  glans  presents  two  malforma-^ 

,    ,  ...  Narrowness         of 

ttons.     Narroivness  of  the  meatus,  predisposing  tc  I 

,,,.,,.  I      the  meatus  .  .  .  p.  412 

urethral  infections I 

.    .    .  and  shortness  of  the  froenum,  which  causes^     , 

,     .  .  ,    ,        ,  ,  Shortness   of   froe- 

teartng  during  coitus,  and  thus  becomes  the  cause  L 

,.,.,,,,,,  nam p.  412 

of  inoculation  of  hard  and  soft  chancres  ...    .J 

Phimosis  is  of  different  kinds.  Sometimes  f/t^-.  Congenital  phi- 
narrowness   of   the   prepuce   is   congenital  .    .    .    .j      mosis p. -;-2 

.    .    .  sometimes,   even  in   the   child,   it   is  acci-^  Inflammatory    phi- 

dental,  temporary  and  inflammatory J      mosis P-4i3 

In   the  adolescent  there  are  two   kinds  of  phi-'] 

.  „  ,      ,  Gonorrhoeal       phi- 

mosis;   one,  mfiammatory  and  ccdematous,  consec-  I 

,  mosis p.  413 

utwe   to  gonorrhoea I 

.    .    .   the   other   due    to    secondary   syphilis;    in"]  _,.,..  ,  . 

,.  ,     ,  .     ,      ,    ^,  ,  Syphilitic         phi- 

which  the  prepuce  is  hard,  fibrous  and  full  of  no-  V 

,     .,.  mosis p.  413 

dosities J 

All  forms  of  balanitis  may  give  rise  to  a  tranA 
sient  consecutive  phimosis;   after  herpes,  for  f«- 1  Herpetic  phimosis  p.  414 
stance J 

.  .  .  but  more  often  after  simple  /rawma^jV"!  Phimosis  of  bal- 
balanitis J      anitis P-4I4 

The  phimosis  of  diabetic  balanitis  is  peculiar  in^ 
aspect    and    easily    distinguished,   as    the    balanitis  LDiabetic     balanitis  p.  414 
which   accompanies  it J 

Lastly  phimosis  may   complicate   the  vegetations-.  Phimosis  of  vege- 

and    balano-posthitis   zvhich    it    causes J      tations P-4i5 

After  this  morbid  series,  the  mechanism  and  treat--.  ^        ,  . 

I  Paraphimosis  .  .  .  p.  415 
ment  of  paraphimosis  zcill  be  explained J 

A  few  words  ivill  be  devoted  to  each  form  of 
balanitis;  first  the  primary  balanitis;  traumatic 
mercurial,  iodide,  pustulo-ulcerative,  erosive,  cir- 
cinate,   etc 

Symptomatic  balanites  will  be  studied  with  their 
causes 

The   lesions   of  scabies   affecting   the  glans  wilh  „     ,  . 

,  .  I  Scabies p.  416 

be  reviewed J 


Primary  balanitis  .  P.41S 


p  Soft  chancre  ...  p.  421 


412  THE    GLANS   AND    PREPUCE. 

.    .    .   also    post-gonorrhcral    vegetations  ....    Vegetations   ....  p.  417 

.    .    .   also    syphilitic    lesions    of    the    glans    and^ 

prepuce:  hard  chancre,  secondary  papules,  common  I  Syphilis p.  418 

and   chancriform   gummata J 

Soft   chancre,   or  chancroid,  will  require  a   dif- 
ferential description 

Herpes  is  the  origin  of  many  errors  in  diagnosis  Herpes p.  422 

Diabetic  lesions  will  be  described;  ulcerative  or^ 
exulcerativc ;    often    misunderstood,    but    of    con- 1  iJiabetides   ....  p.   423 
siderable   diagnostic  importance J 

Lastly,  mention  will  be  made  of  lichen  planus,  \  .         ' 

,     .  •  ,    ,•  W Tuberculosis   .    .   .  p.  424 

tuberculosis  and  epithelioma K-  ■  ,    ,• 

J  Epithelioma  ....  p.  424 

NARROWNESS    OF   THE    MEATUS. 

Congenital  narrowing  of  the  meatus  is  a  condition  which  nearly 
always  leads  to  a  chronic  microbial  state  of  the  navictilar  fossa;  the 
increase  in  size  combined  with  slight  irritation  of  the  surface  pre- 
disposing to  contagion.  The  meatus  may  easily  be  enlarged  by 
a  slight  snip  with  the  scissors. 

Gonorrhoea  often  leaves  behind  it  a  persistent  irritation  of  the 
navicular  fossa,  when  the  meatus  is  too  narrow;  also,  vegetations 
may  occur  there. 

SHORTNESS  OF  THE  FROENUM. 

Shortness  of  the  froenum  is  a  more  important  malformation,  for 
transverse  lacerations  may  occur  at  each  coitus,  and  expose  the  sub- 
ject to  any  infection  which  he  may  risk.  Ruptured  froenum  is 
often  marked  at  each  end  by  two  small  cutaneous  masses,  about 
half  an  inch  apart.  Many  soft  and  hard  chancres  and  vegetations 
no  doubt  occur  at  the  seat  of  a  ruptured  froenum.  Division  of  the 
froenum  with  scissors  should  be  practised  on  all  infants,  when  it  is 
too  short.  The  froenum  contains  a  small  artery  which  may  require 
ligature  after  section. 

PHIMOSIS. 

By  the  name  phimosis  is  understood  the  condition  in  which  it  is 
impossible  to  expose  the  glans  penis,  on  account  of  the  acquired  or 
congenital  narrowing  of  the  prepuce.  Phimosis  is  of  considerable 
clinical  importance. 


THE    GLANS    AND    PREPUCE.  413 

In  the  child  phimosis  may  be  congenital  or  accidental.  When 
congenital,  which  is  more  common,  it  varies  in  degree  of  tightness ; 
severe  cases  require  circumcision  or  incision ;  less  marked  cases  dila- 
tation by  forceps.  Congenital  phimosis  is  sometimes  accompanied 
by  adhesion  of  the  prepuce  to  the  glans  by  veritable  synechise,  which 
require  to  be  ruptured. 

The  child  may  also  present  inflammatory  phimosis,  with  local  pain 
and  oedema.  This  is  rare  and  is  due  to  a  balano-posthitis  caused  by 
accumulation  of  smegma,  or  to  rough  cleansing;  sometimes,  perhaps,, 
to  the  practice  of  masturbation.  In  these  cases  boric  acid  lotion 
should  be  injected  several  times  a  day  between  the  glans  and  the 
prepuce.  In  two  or  three  days  the  glans  may  be  exposed  and  the 
balano-posthitis  treated  according  to  its  cause. 

In  the  adolescent  and  adult  phimosis  may  be  due  to  very  different 
causes,  the  commonest  of  which  are  syphilis  and  gonorrhoea.  The 
characters  of  these  differ  considerably. 


GONORRHOEAL   PHIMOSIS. 

The  penis  is  large,  pendulous,  much  swollen  and  painful  and  red 
at  the  extremity.  Pus  emerges  from  the  prepuce,  and  can  be  seen  to 
be  gonorrhoeal  if  the  meatus  is  visible ;  if  not  a  microscopic  prepara- 
tion may  be  made.^  If  there  are  no  gonococci  the  case  is  one  of 
balano-posthitis.  If  it  is  a  case  of  gonorrhoea  it  should  be  treated 
by  local  irrigation,  moist  dressings,  etc.,  and  when  the  inflammation 
has  subsided  irrigation  of  the  urethra  with  permanganate  ( i  in  10,- 
000  to  I  in  1,000).  For  technical  details  see  the  treatises  on  venere- 
ology. If  there  is  balano-posthitis  treat  with  injections  under  the 
prepuce. 

SYPHILITIC   PHIMOSIS. 

The  phimosis  of  secondary  syphilis  is  quite  another  thing.  The 
penis  is  much  less  enlarged  and  painless.  The  prepuce  is  increased 
in  size  anfl  sometimes  irregular,  purple  in  colour,  and  feels  as  hard 
as  india-rubber. 

1  Spread  a  trace  of  pus  on  a  slide;  dry,  and  fix  by  passing  two  or  three 
times  through  a  flame;  stain  for  3  minutes  with  Unna's  polychromatous 
blue;  wash  with  water;  dry  and  examine  under  an  immersion  lens  with 
a  drop  of  cedar  oU. 


414  THE  GLANS  AND  PREPUCE. 

The  glans  penis  cannot  be  exposed,  owing  to  the  sclerous  ring  of 
the  prepuce.  A  number  of  nodosities  can  be  felt  through  the  pre- 
puce due  to  the  induration  of  primary  chancres,  or  secondary  papules. 
The  satellite  gland  may  be  discovered  in  the  groin,  and  a  roseola  or 
secondary  papular  eruption  may  be  found  on  the  body.  The  hard 
indolent  prepuce  with  lym.phangitis  or  phlebitis  of  the  furrow,  hard 
and  indolent,  is  easy  to  diagnose,  and  is  not  comparable  to  any 
other  affection.  The  prepuce,  which  appears  impossible  to  dilate, 
recovers  its  suppleness  under  appropriate  general  treatment. 


PHIMOSIS    OF   BALANITIS. 


All  forms  of  balanitis  may  give  rise  to  secondary  phimosis.  An 
inflammatory  phimosis  may  occur  after  herpetic  balanitis  (p.  422). 
In  this  case  the  preputial  orifice  discharges  a  slight  brownish  exuda- 
tion, streaked  with  blood.  This  phimosis  is  not  absolute,  and  the 
glans  may  be  uncovered,  but  the  process  is  painful.  Diagnosis  may 
be  only  hypothetical.  The  case  should  be  treated  by  sub-preputial 
irrigations  with  boric  lotion  or  sulphate  of  zinc  (l  in  200). 

In  common  balanitis  phimosis  indicates  a  high  degree  of  inflam- 
mation ;  treatment  is  the  same,  by  hot  fomentations. 

Phimosis  due  to  diabetic  balanitis  may  occur  in  middle  aged  obese 
subjects.  The  prepuce  is  somewhat  hard  and  swollen  and  often 
presents  painful  radiating  fissures.  A  gummy  semi-purulent  liquid 
may  be  pressed  from  the  preputial  orifice,  in  small  quantities.  Pal- 
pation reveals  a  crown  of  painful  points  in  the  region  of  the  balano-* 
preputial  furrow,  where  diabetic  ulcers  are  situated.  Sugar  is  found 
in  the  urine  (see  page  423). 

Phimosis  may  accompany  vegetations  (p.  417),  either  because  the 
vegetations  have  increased  the  size  of  the  glans,  or  because  they  have 
set  up  an  acute  balano-posthitis  and  inflammatory  phimosis.  The 
inflammation  may  even  lead  to  gangrene  of  the  prepuce.  In  this 
case  the  circumcision  should  be  completed.  In  the  first  case  the  in- 
flammatory phimosis  may  be  treated  after  the  vegetations  have  been 
removed. 

Lastly,  accidental  obstacles,  such  as  an  epithelioma  or  chancriform 
gumma,  may  cause  phimosis. 


THE  GLANS  AND  PREPUCE.  415 

PARAPHIMOSIS. 

When  the  prepuce  is  tight  and  there  is  a  slight  degree  of  phimosis, 
if  it  is  drawn  back  to  the  furrow  it  may  not  be  able  to  return;  the 
phimosis  has  become  a  paraphimosis.  The  resulting  stricture  causes 
swelling  of  the  glans  which  opposes  more  and  more  the  return  of 
the  prepuce  to  its  normal  place.  The  prepuce,  owing  to  its  obstructed 
circulation,  becomes  oedematous. 

This  condition  if  left  to  itself  may  lead  to  gangrene,  but  the 
patient  generally  seeks  relief  as  soon  as  possible. 

Treatment  consists  in  the  application  of  vaseline  to  the  whole 
region  and  enveloping  it  in  a  compress ;  then  the  penis  is  grasped  in 
the  hand  and  slowly  compressed  for  two  or  three  minutes,  to  remove 
the  oedema.  At  the  same  time  the  prepuce  is  pressed  forward  and 
resumes  its  normal  position. 

PRIMARY    BALANITIS. 

Balanites  or  balano-posthites ;  inflammation  of  the  glans,  balano- 
preputial  furrow  and  prepuce  are  numerous.  They  may  be  primary 
or  secondary. 

TRAUMATIC  BALANITIS. 

This  consists  in  a  more  or  less  abundant  suppuration,  chiefly  of 
the  balano-preputial  furrow,  accompanied  by  pain  and  oedema.  It 
is  cased  either  by  stagnation  of  smegma  or  by  repeated  cleansing 
after  a  suspicious  coitus.  Treatment  consists  in  repeated  irrigation 
wath  boiled  water  containing  camomile ;  oxide  of  zinc  ointment,  and 
the  avoidance  of  coitus. 

MERCURIAL    BALANITIS. 

Acute  local  mercurialism,  erythematous  or  suppurative,  has  been 
observed  after  the  application  of  calomel  to  vegetations,  or  with 
mercurial  ointments  applied  to  chancres.  The  causes  must  be  sup- 
pressed and  the  parts  treated  by  irrigation,  baths  and  simple  oint- 
ments. 

IODIDE    BALANITIS. 

This  may  occur  in  iodism,  but  is  rare.  It  may  assume  the  neo- 
plastic or  ulcerative  form,  like  the  cutaneous  lesions  of  the  jame 
origin.  The  cause  must  be  suppressed,  and  moist  dressings  and 
simple  ointments  applied. 


4i6 


THE    GLANS    AND    PREPUCE. 


PUSTULO-ULCERATIVE    BALANITIS. 

The  ulcerations  have  the  size,  appearance  and  topography  of  true 
herpes,  but  they  suppurate  from  the  first ;  the  ulcers  are  deeper ;  the 
eruption  is  formed  by  sub-acute  attacks  and  does  not  recur,  like 
herpes.  Du  Castel  regards  it  as  contagious.  The  cause  is  unknown 
and  the  treatment  the  same  as  above. 


CIRCINATE   EROSIVE   BALANITIS. 

This  was  described  by  Bcrdal  and  Bataillc.  It  is  a  contagious, 
inoculable  balano-posthitis,  appearing  at  first  as  a  white  accumula- 
tion of  epithelium  which  enlarges; 
the  centre  consisting  of  exulcer- 
ated  epidermis,  while  the  sharply 
defined  lesion  is  limited  by  a 
border  of  white  accumulated  epi- 
thelial debris.  The  centre  of  the 
lesion  heals,  while  the  periphery 
enlarges.  In  the  debris  spirilla 
are  found.  They  may  be  stained 
by  eosine  or  fuchsine  in  extempo- 
raneous preparations,  but  cannot 
be  cultivated. 

INIild  cases  heal  in  4  or  5  days; 
^^.  ^.:. .,<>..,- -..jj^^^  otherwise    nitrate    of    silver    (i    in 

'^'>^*'^>'f*SSg^^H|^^K  ^o),  and  calomel  and  tannin  oint- 

ment (i  per  cent)  may  be  applied. 

SECONDARY    BALANITIS. 

Secondary  balanitis  may  co-exist 
with  vegetations,  herpes,  chancre 
or  syphilitic  papules  and  will  be 
referred  to  with  each  of  these  le- 
sions. They  are  easily  recognised 
and  treated  in  the  same  way  as  pri- 
mary balanites.  Diabetic  balanitis  is 
referred  to  under  the  name  of  dia- 
betides  (p.  423). 


Fig.  180 

nier's 
seum. 


Scabies  of  Penis.  (Four- 
patient.  St.  Liouis  Hosp.  Mu- 
No.    765.) 


THE   GLANS   AND    PREPUCE. 


417 


SCABIES. 

The  burrows  of  scabies  in  the  glans  penis  are  common  and  path- 
ognomonic. Many  lesions,  which  at  first  sight  cannot  be  declared 
as  scabies,  are  confirmed  by  the  sarcoptic  lesion  of  the  glans  or 
penis  (p.  425). 

On  the  glans  the  older  lesions  form  round,  red,  flat,  almost 
papular  spots,  on  the  surface  of  which  the  fine  folds  of  skin  of  the 
glans  are  effaced.  The  younger  lesions  consist  of  vesicles  or 
burrows,  often  excoriated.  The  burrow  may  be  quite  distinct,  red 
and  irregular. 

The  lesion  of  scabies  on  the  glans  is  thus  polymorphous  and  not 
characteristic,  but  its  localisation  is  more  so.  Syphilitic  papules  and 
psoriasis  of  the  glans  are  rare,  and  the  surface  of  the  glans  scarcel> 
ever  presents  anything  comparable  to  the  vesicular,  erosive  lesions 

of  scabies.  The  diagnosis  of 
scabies  is  certified  by  the  presence 
of  similar  lesions  on  the  furrow 
and  penis.  (For  treatment  see 
page  537-) 

VEGETATIONS. 

Vegetations  (cauliflower  or 
cockscomb)  consist  of  small  pa- 
pillomatous tumours  situated  on 
the  genital  regions  of  both  sexes; 
in  the  male,  sometimes  at  the 
urethal  orifice,  but  more  often  in 
the  balano-preputial  furrow  or  the 
internal  surface  of  the  prepuce. 

A  small  simple  papular  projec- 
tion forms  at  first,  which  soon  di- 
vides in  digitations;  these  multi- 
ply but  retain  their  single  pedicle. 
Other  similar  papules  develop  and  multiply  in  the  same  way.  After 
a  time  the  projecting  digitated  tumours  closely  resemble  a  cauli- 
flower in  appearance.  They  are  pink  and  covered  with  epidermis 
and  when  multiple  the  opposed  surfaces  secrete  a  purulent  micro- 
bial fluid  with  an  infectious  odoiu".     These  small  tumours  act  as 


Fig.  181.     Vegetations.  (Guiboufs 

patient.      St.    Louis    Hosp.    Museum, 

No.    78.) 


V 


4i8  THE  GLANS  AND  PREPUCE. 

foreign  bodies  between  the  glans  and  prepuce  and  cause  constant 
suppuration. 

The  affection  exists  in  different  degrees.  The  most  pronounced 
correspond  to  the  figure;  medium  cases  to  the  preceding  descrip- 
tion. SHght  cases  comprise  one  or  two  rows  of  small  digitated 
papules,  in  the  balano-preputial  furrow,  or  along  the  froenum,  and 
one  or  two  papules  at  the  meatal  orifice. 

Vegetations,  according  to  many  venereologists,  are  connected  with 
gonorrhoea,  and  according  to  them  never  occur  in  patients  who  have 
not  had  gonorrhcea.  Experimental  proof  of  this  opinion  is  wanting, 
but  it  seems  to  correspond  to  clinical  observation. 

These  lesions,  when  they  are  not  well  treated,  are  very  tenacious, 
recurrent  and  distressing  to  the  patient.  They  require  continual 
and  careful  cleanliness,  and  repeated  treatment.  The  vegetations 
should  be  touched  with  crystals  of  chromic  acid,  taking  care  to  avoid 
the  healthy  skin.  The  patient  can  apply  daily  a  powder  of  2  parts 
powdered  savin,  3  parts  salicylic  acid  and  3  parts  powdered  talc. 

By  this  treatment  vegetations  may  be  cured  in  2  or  3  months,  but 
recurrences  must  be  watched  for. 

HARD    CHANCRE. 

The  hard  chancre,  the  initial  lesion  of  syphilis,  is  more  frequent 
in  this  situation  than  elsewhere.  It  appears,  from  15  to  30  days 
after  the  infectious  coitus,  in  the  form  of  a  red,  non-exudative  lesion, 
in  the  centre  of  which  the  horny  epidermis  disappears  by  simple 
friction.  Inoculation  in  the  monkey  show  that  the  initial  lesion  is  a 
flat  vesicle,  which  is  almost  immediately  destroyed.  In  practice  this 
commencement  is  not  observed,  and  the  first  thing  seen  is  the  exul- 
ceration.  This  is  flat,  non-excavated,  slightly  moist  but  not  sup- 
purating, and  enlarges  from  day  to  day  to  attain  a  maximum  of 
3-5  inch,  30  days  after  coitus. 

As  the  sore  enlarges  a  cartilaginous  induration  develops  under- 
neath it,  larger  than  the  exulceration.  This  resembles  a  disc  of 
cardboard  enclosed  in  the  skin.  The  chancre  remains  for  4  to  6 
weeks;  after  the  fourth  week  the  eroded  surface  contracts  and 
becomes  epidermised,  but  the  induration  persists  for  a  long  time 
and  may  be  felt  2  or  3  months  later. 

Hard  chancres  vary  in  size  in  different  cases,  and  the  one  described 
is  an  average  case.     It  is  usually  single,  but  there  are  many  excep- 


THE    GLANS    AND    PREPUCE.  419 

tions  to  this  rule.    A  large  chancre  may  be  followed  in  a  few  days 
by  smaller  ones. 

After  the  first  few  days  of  the  chancre  one  of  the  glands  of  the 
groin  enlarges,  on  the  same  side  as  the  chancre;  this  is  the  satellite 
gland.  It  becomes  double  its  normal  size,  very  resistant  and  remains 
for  months  without  suppurating.  A  few  days  later  the  neighbour- 
ing glands  are  affected,  forming  the  "pleiad,"  but  they  do  not  attain 
the  size  of  the  satellite  gland.    They  are  all  painless. 


rig:.  183.     Indurated    chancre    of    penis.    (Jeanselme's   patient.     Photo,    by    NoirS.) 

The  situation  of  the  chancre  is  variable.  It  is  often  seen  on  the 
froenum,  especially  when  this  is  short  and  ruptured  during  coitus ; 
it  is  also  frequent  in  the  balano-preputial  furrow  near  the  froenum, 
or  on  the  prepuce.  It  may  occur  at  the  meatus,  giving  the  appear- 
ance of  eversion  of  the  mucous  membrane,  but  it  is  usually  unilat- 
eral. Chancre  may  occur  in  the  urethra  and  is  the  origin  of  numer- 
ous errors  in  diagnosis.  It  irritates  the  mucosa,  which  secretes 
muco-pus ;  a  superficial  examination  leads  to  the  diagnosis  of  gon- 
orrhcea ;  after  a  few  days  the  discharge  ceases  and  the  patient 
thinks  he  is  cured  of  his  so-called  clap;  but  the  induration  under 
the  glans  penis  can  be  felt.  Chancre  of  the  urethra  is,  however,  rela- 
tively rare. 

The  lymphatic  glands  of  the  urethra  are  pelvic  and  lumbar,  and 
the  absence  of  palpable  glands  may  add  to  uncertainty  in  the  diag- 
nosis, till  the  appearance  of  secondary  lesions. 


420  THE  GLANS  AND  PREPUCE. 

Every  previous  erosion  favours  syphilitic  infection*  Although 
clinical  experience  seems  to  show  that  the  skin  and  mucous  mem- 
brane, when  intact,  are  not  easily  inoculated  by  syphilis  during 
coitus  and  may  escape  inoculation,  on  the  other  hand  the  erosions 
of  multiple  coitus,  especially  that  of  the  froenum,  and  also  erosions 
caused  by  scabies,  render  inoculation  almost  inevitable.  The  pro- 
portion of  patients  presenting  scabies  in  association  with  hard  chan- 
cre, at  the  St,  Louis  Hospital,  is  considerable. 

Hard  chancre  may  develop  at  the  same  time  and  in  the  same  place 
as  a  chancroid.  In  this  case  it  is  often  unrecognised,  for  it  is  then 
ulcerated  and  suppurating,  and  the  only  remaining  characteristic  is 
the  induration.  The  glandular  changes  should  be  carefully  watched 
and  the  appearance  of  a  satellite  gland,  non-inflammatory  and  non- 
painful,  should  make  the  diagnosis  guarded. 

The  local  treatment  of  indurated  chancre  is  nil.  The  treatment  of 
syphilis  (p.  650)  should  be  commenced  at  once.  This  is  the  opinion 
which  tends  to  prevail  more  and  more  at  the  present  day,  when  most 
syphilographers  are  in  favour  of  rapid  and  intense  treatment.  Many, 
however,  even  recently,  wait  for  the  appearance  of  the  roseola  before 
treatment.    This  would  appear  to  lose  valuable  time. 

It  may  be  noted  that  the  indurated  chancre  leaves  only  a  flat  and 
hardly  visible  cicatrix,  which  often  disappears  completely  in  the 
course  of  time.  A  deep  or  depressed  cicatrix  in  this  situation  does 
not  represent  a  former  indurated  chancre. 


SYPHILIDES. 

Hard  chancre  is  the  first  and  the  most  important  of  the  syphilides 
of  this  region,  but  there  may  be  many  others. 

(i)  Secondary  papular  syphilides,  more  or  less  numerous,  dis- 
seminated on  the  surface  of  the  glans  and  the  internal  surface  of 
the  prepuce.  By  their  multiplicity  and  induration  they  cause  syphil- 
itic phimosis. 

(2)  Tertiary  serpiginous  syphilides  and  local  gummata  are  some- 
what rare  and  present  nothing  peculiar  in  this  situation  except  the 
cicatrix  which  they  leave.  Others,  the  so-called  chancriform  gum- 
mata, may  present  a  remarkable  resemblance  to  the  initial  lesion. 
These  gummata  have  given  rise  to  the  belief  in  double  syphilis,  or 
reinoculation  of  syphilis  in  an  old  syphilitic  subject,  of  which  there 


THE    GLANS    AND    PREPUCE.  421 

does  not  appear  to  be  a  single  authentic  example  (A.  Fonrnier)^ 
These  so-called  chancres  are  not  followed  by  glandular  induration, 
roseola,  etc.  They  remain  the  same  till  cured  by  treatment  and 
leave  a  cicatrix  which  is  much  more  marked  than  in  true  syphilitic 
chancre. 

SOFT    CHANCRE. 

Soft  chancre  or  chancroid  appears  from  the  4th  to  8th  day  after 
the  infectious  coitus,  in  the  form  of  a  vesiculo-pustule  which  soon 
ulcerates.  It  then  forms  a  small  ulceration  of  the  same  depth  and 
width,  w^hich  enlarges  from  day  to  day  in  all  directions.  There  is 
considerable  suppuration,  and  the  pus,  which  is  very  contagious,  may 
multiply  the  chancres  around  the  first  one.  Multiple  soft  chancres 
are  the  rule,  and  the  region  may  be  covered  with  them.  They 
occupy  the  froenum,  the  balano-preputial  furrow,  the  prepuce  and 
the  glans. 

They  form  punched  out  suppurating  ulcers,  with  a  fine  red  bor- 
der. They  are  very  characteristic  and  can  hardly  be  mistaken  for 
anything  except  the  vesico-pustules  of  progenital  herpes  (p.  422). 
But  while  the  vesico-pustules  of  herpes  are  agglomerated  in  a  group, 
the  chancroids  are  placed  irregularly.  IMoreover,  the  herpetic  vesicle 
is  not  punched  out,  is  more  regular  and  does  not  suppurate. 

The  reinoculation  of  soft  chancre  is  a  method  employed  since  the 
time  of  Ricord  to  prove  its  nature.  The  pus  of  the  initial  chancre  is 
inoculated  in  the  arm  of  the  same  patient.  It  forms  a  pustule  which 
reproduces,  usually  in  an  attenuated  form,  all  the  symptoms  of  the 
initial  chancroid.  When  their  nature  has  been  proved  they  are 
treated  with  sulpho-carbon  paste  which  acts  as  a  caustic.  They  may 
also  be  treated  by  iodoform  powder  or  ointment,  tannoform,  sub- 
carbonate  of  iron,  etc.  The  lesion  is  very  little  resistant  to  antisep- 
tics. Nevertheless  it  sometimes  becomes  phagedenic  (see  Fig.  120). 
The  true  causes  of  phagedena  are  not  known ;  it  is  rare  at  the 
present  time,  probably  because  soft  chancres  are  more  rapidly 
treated. 

1  Translator's  Note.  It  is  true  that  the  chancriform  gumma  may  have 
led  to  the  erroneous  diagnosis  of  a  second  infection  in  some  instances; 
but  so  many  cases  of  re-infection  have  been  reported  by  competent 
authorities,  in  which  the  chancres  appeared  in  different  situations  at  the 
two  infections,  that  second  attacks  of  syphilis,  or  re-infection,  must  be 
accepted  as  an  established  fact.  (Vide  Translator's  book  on  Syphilis  and 
Gonorrhoea.) 


422  THE  GLANS  AND  PREPUCE. 

Microscopic  examination  is  easy  in  the  case  of  a  young  chancre. 
Pus  scraped  from  the  border,  fixed  and  stained  by  ordinary  methods, 
shows  a  strepto-bacilhis  in  chains  (Dticrey-Unna).  The  pus  from 
the  chancre  shows  the  same  microbe  in  a  diplococcic  form,  the 
bacillus  only  staining  at  the  two  ends. 

Soft  chancre  may  only  give  rise  to  slight  glandular  reaction;  or 


^M'XfC^J^ 


Fig.  183.     Bacillus   of  Ducrey  from   soft   chancre.     Fibrinous   exudation\ 
from    the    walls.      (Obj.    1-12.    Oc.    3    Leitz. 

one  of  the  glands  may  become  acutely  inflamed,  forming  the  bubo 
of  soft  chancre,  which  was  studied  in  the  region  of  the  groin  (p. 
270). 

The  cicatrix  of  soft  chancre  is  always  more  distinct  than  that  of 
hard  chancre.  It  remains  visible  indefinitely,  and  is  sometimes  sunk 
in  the  skin,  preserving  the  sharply  cut  edges  of  its  initial  state. 

HERPES    PROGENITALIS. 

Herpes  progenitalis  consists  in  an  eruption  of  herpetic  vesico- 
pustules,  grouped  in  the  form  of  a  bouquet,  appearing  in  one  or  tvv'O 
days  on  some  part  of  the  congenital  organs,  more  often  in  the 
balano-preputial  furrow ;  lasting  7  or  8  days,  and  disappearing  on 
the  loth  or  12th.    The  eruption  is  very  liable  to  recurrences. 


THE    GLANS    AND    PREPUCE.  423 

The  vesicles  occur  in  groups  of  6  to  12 ;  each  one  oval,  and  mostly 
arranged  with  the  larger  axis  in  the  same  direction.  The  eruption 
is  preceded  by  itching  and  smarting,  when  a  white  spot  under  the 
epidermis  marks  the  situation  of  each  vesicle ;  on  the  next  day  the 
turbid  vesicles  appear,  in  the  form  of  half  an  egg  cut  longitudinally. 

The  largest  are  3  millimetres  long  and  2  wide.  They  are  opened 
by  scratching  or  dry  up  in  situ.  When  opened  each  vesicle  forms  a 
round,  red  erosion  with  a  clearly  cut  margin.  They  suppurate 
slighly  on  one  day  and  dry  up  on  the  next,  leaving  a  brownish  scab, 
preserving  the  form  of  the  lesion.  Herpes  recurs  in  the  same  place, 
or  near  it,  an  indefinite  number  of  times;  every  month,  after  every 
strange  coitus,  or  without  any  appreciable  cause.  It  often  causes 
nervous  depression,  and  many  herpetic  patients,  in  spite  of  affirma- 
tions to  the  contrary,  believe  themselves  to  be  syphilitic  and  regard 
their  relapses  as  outbreaks  of  mucous  patches.  Others  are  afraid 
of  being  inoculated  with  syphilis  by  the  herpetic  erosions  and  remain 
indefinitely  chaste.  It  is  a  fact  that  all  doubtful  sexual  connexion  is 
rendered  more  dangerous  by  these  erosions. 

There  is  no  satisfactory  treatment  for  herpes.  Daily  local  bath- 
ing with  carbolic  lotion  (2  per  cent)  is  one  of  the  best  preventive 
methods.  All  kinds  of  powders  and  ointments  have  been  prescribed 
for  herpes,  with  variable  success. 


DIABETIDES. 

The  diabetides  have  no  physiognomy  of  their  own ;  it  is  their  nega- 
tive characters  which  suggest  diabetes. 

For  instance,  a  man  between  40  and  55  years,  rather  obese  and 
florid,  complains  of  erosions  caused  during  coitus,  which  have  not 
healed  for  two  months  or  more.  On  examination,  disseminated 
erosions  are  found  in  the  balano-preputial  furrow,  slightly  exuda- 
tive and  crusted,  easily  bleeding;  with  no  resemblance  to  mucous 
patches,  chancres,  scabies  or  any  ordinary  lesion  of  this  situation. 
In  such  a  case  diabetes  should  be  suspected  and  the  urine  examined. 

General  treatment  of  diabetes  and  strict  diet  are  necessary;  local 
treatment  comprises  the  use  of  powders,  such  as  dermatol,  tanno- 
form  or  oxide  of  zinc ;  or  better  still  the  sub-carbonate  of  iron  oint- 
ment (i  in  40). 


424  THE  GLANS  AND  PREPUCE. 

As  a  rule  the  diabetides  heal  when  the  sugar  diminishes;  but  they 
may  recur  when  the  glycosuria  returns,  so  as  to  cause  the  patient 
much  distress.  However,  about  three-quarters  of  the  cases  yield 
definitely  to  treatment, 

LICHEN    PLANUS. 

Lichen  planus  of  the  prepuce  and  glans  is  only  an  epiphenomenon 
in  the  course  of  the  general  eruption.  Here,  as  elsewhere,  the  erup- 
tion is  formed  by  a  multitude  of  small,  flat,  raised,  smooth,  shining 
papules,  of  a  violet-lilac  colour,  grouped  or  scattered  in  different 
cases,  and  with  a  surface  traversed  by  fine  white  lines. 


TUBERCULOSIS. 

I  have  once  seen  cutaneous  and  sub-cutaneous  tubercle  of  the 
glans  penis.  It  consisted  of  a  placard  covering  one-third  of  the 
surface  and  gave  the  part  a  peculiar  resistance.  It  developed  slowly 
and  invaded  the  corpus  spongiosum  without  causing  functional 
trouble,  the  mucosa  of  the  urethra  remaining  intact.  A  biopsy  con- 
firmed the  diagnosis. 

EPITHELIOMA. 

Epithelioma  of  the  glans  is  not  very  common.  It  occurs  in  the 
form  of  a  raised  growth,  sometimes  pedunculated ;  sometimes  in 
framboesiform  masses,  from  which  almost  liquid  epithelial  agglom- 
erations can  be  pressed  out  like  vermicelli.  Treatment  by  X-rays 
should  be  attempted  after  removal,  or  without  it. 


THE  SHEATH  OF  THE  PENIS. 

/  shall  first  consider  sebaceous  cysts  which  are 
very  common  in  this  region,  and  by  their  number  -Sebaceous    cysts   .  p.  425 
may  cause  a  slight  deformity 

Simple   or  pustular  scabies  causes  characteristic  I  c     1  • 

.         .       ^         ,      .      ,  .  Lbcabies p.  42'5 

?urrows  and  vesico-pustules  tn  this  region  ....  J  *-  -r-. 

Herpes,   with   its  recurring   vesicular   eruptionSjljr  -- 

is  an  almost  perpetual  affliction  in  some  subjects  .J 

Syphilitic    lesions;    chancre,    secondary    papules\c     ,  ...  ^ 

and  tertiary  gummata  will  be  dealt  with   ....  J  

.    .    .  also  soft  chancres,  which  are  rather  rare']  c-   t^     1 
,,  .           .  ^boit  chancre  .  .  .  p.  427 

in    this   region J  ^  ^^' 

On  the  hypogastric  region  and  on  the  sheath  oH 

the  penis,   occurs   a   form   of  psoriasis  with   fatty  Isteatoid    .psoriasis  p.  427 

squames 

/  shall  conclude  with  a  description  of  spot.laneous\  „ 

,     .         ,    ^  .,,       .     •  I    Spontaneous     gan- 

gangrene;    a    rare    lesion,    but    one    with    special  Y  „ 

characters J      ^'"'"^ ^'^^ 

SEBACEOUS    CYSTS. 

The  sheath  of  the  penis  is  a  common  situation  for  true  sebaceous 
cysts  (p.  620)  ;  i.e.,  retention  cysts  which  can  be  emptied  by  pres- 
sure. A  thin,  white,  caseous  filament,  Hke  vermicelh,  emerges  from 
an  imperceptible  orifice. 

These  cysts  are  the  size  01  a  pea,  and  are  very  common  in  certain 
subjects.  They  may  be  cured  by  puncture  with  the  galvano-cautery 
and  evacuation  of  the  contents,  followed  by  the  application  of  tinc- 
ture of  iodine  to  the  wall  of  the  cyst.  Certain  intoxications  favour 
the  production  of  sebaceous  cysts  on  the  penis  and  scrotum,  such  as 
occurs  in  workers  in  chlorine.  In  such  cases  suppression  of  the 
cause  is  the  first  point  in  treatment. 


SCABIES. 

The  sheath  of  the  penis  is  a  common  region  for  the  acarus  scabiei. 
Scabies  is  only  contracted  at  night,  because  the  acarus  is  nocti- 
ambulatory,  and  sexual  connection  is  the  usual  cause  of  contagion. 
Well  marked  scabies  in  men  is  always  accompanied  by  scabies  of  the 
penis.     The  lesions  consist  of  raised  irregular  burrows;  red,  pru- 


426  THE    SHEATH    OF   THE    PENIS. 

riginous,  disseminated  and  sometimes  connected  with  a  vesico-pus- 
tule.  Suppurative,  polymorphous,  vesico-pustular  lesions  are  much 
less  common  on  the  penis  than  on  the  hands. 

In  conclusion :  ( i )  never  diagnose  scabies  in  men  without  having 
verified  the  existence  of  lesions  on  the  penis;  (2)  remember  that 
scabies  is  undoubtedly  the  most  common  of  the  pruriginous  lesions 
of  the  sheath  of  the  penis.     For  treatment  see  page  537. 

HERPES. 

Herpes  of  the  penis  is  common.  It  may  occur  on  the  external 
surface  of  the  prepuce,  or  at  the  base  of  the  penis,  in  the  form  of  a 
single  or  double  group  of  5  to  10  vesicles.  These  soon  become  pus- 
tular and  form  white  spots  on  a  common  red  base,  at  first  flattened, 
but  afterwards  slightly  projecting. 

The  eruption  develops  in  about  two  days  with  local  itching  and 
smarting.  It  lasts  for  5  or  6  days  and  disappears  in  2  or  3  days, 
having  lasted  from  10  to  12  days  altogether.  The  erythematous 
patch  common  to  all  the  vesicles  subsides,  all  except  a  thin  red  areola 
round  each  vesicle,  which  in  its  turn  disappears  when  the  eruption 
is  gone. 

A  man  is  subject  to  herpes  from  20  to  200  times  in  his  life  and 
the  attacks  arise  after  known  causes;  such  as  coitus,  migraine,  gas- 
tric disorders,  angina,  or  without  any  perceptible  cause.  The  crop 
of  herpes  at  the  base  of  the  penis  often  recurs  exactly  in  the  same 
place;  on  the  prepuce  it  is  more  varied  in  localisation. 

General  treatment  is  directed  against  the  exciting  cause  when 
this  is  known.  Local  treatment  consists  in  the  daily  application  of 
carbolic  lotion  (2  per  cent).  At  the  end  of  the  eruption  equal  parts 
of  glycerine  of  starch  and  resorcine  may  be  applied ;  or  a  powder  of 
equal  parts  of  talc,  oxide  of  zinc  and  starch. 

HARD   CHANCRE. 

Indurated  chancre  of  the  sheath  or  the  base  of  the  penis  is  not 
uncommon.  It  is  generally  grafted  on  a  pre-existing  scabies.  It  is 
often  of  larger  size  than  the  balano-preputial  chancre  and  its  long 
axis  often  follows  the  scabies  burrow.  In  character  and  mode  of 
evolution  it  resembles  chancre  of  the  glans  (p.  418). 


THE    SHEATH    OF   THE    PENIS.  4:27 

SECONDARY    SYPHILIS. 

The  secondary  eruption  of  macules  and  papules  may  occur  on  the 
penis  as  elsewhere,  especially  on  the  preputial  fold,  where  the 
accumulation  of  papules  and  hard  oedema  accompanying  them,  create 
the  syphilitic  phimosis  described  on  page  413.  Also,  lymphangitis 
and  phlebitis  secondary  to  the  chancre  may  be  felt  as  hard  cords 
along  the  penis.    These  entirely  disappear  under  treatment. 

TERTIARY    SYPHILIS. 

Tertiary  syphilis  seldom  occurs  on  the  sheath  of  the  penis  except 
in  the  form  of  an  accidental  gumma.  It  forms  a  rounded  or  oval, 
painless  tumour,  of  slow  evolution.  On  its  surface  the  skin  is  pur- 
ple, thin  and  cold.  It  becomes  fixed  and  ulcerated  and  gradually 
discharges  a  yellow  core.  Immediate  treatment  is  indicated,  and  in 
doubtful  cases  a  therapeutic  test  of  3  weeks. 


SOFT   CHANCRE. 

Soft  chancres  are  rarely  seen  on  the  sheath  of  the  penis.  They 
usually  occur  around  the  glans  or  in  the  radiating  folds  of  the  closed 
prepuce.  They  present  their  usual  characters ;  irregular  ulcers  with 
red  borders,  punched  out,  suppurative,  non-indurated  and  easily 
curable  by  local  cleanliness  and  the  application  of  mild  antisep- 
tics. 

PSORIASIS. 

There  is  a  clinical  type  of  psoriasis  with  an  elective  localisation 
for  the  inguinal  and  genital  regions,  accompanied  by  a  few  lesions 
of  the  same  type  on  the  scalp.  On  the  penis  and  hypogastrium  it 
forms  rose  coloured  spots ;  less  red,  infiltrated  and  squamous  than 
those  of  typical  psoriasis. 

The  squames  are  pityriasiform,  yellowish  white  and  fatty;  the 
type  of  steatoid  psoriasis  of  adolescents  and  seborrhoeics. 

The  treatment  is  that  of  psoriasis  of  other  regions,  but  requires 
rather  mild  applications : — 


428 


THE    SHEATH    OF   THE   PENIS. 


Resorcine  . 
Ichthyol  .  . 
Oil  of  birch 
Oil  of  cade 
Vaseline  .  . 
Lanoline    . . 


-   aa     I  gramme    \-  aa  gr. 


aa  10  grammes 


aa 


Si 


It  is  of  a  benign  character  and,  when  taken  in  time,  may  disappear 
without  too  frequent  or  too  obstinate  recurrences. 

SPONTANEOUS   GANGRENE. 

This  cHnical  type,  which  is  fortunately  rare,  is  very  characteristic 
in  all  its  symptoms. 

After  a  puncture  or  erosion,  or  even  without  any  traumatism, 
there  develops  in  a  few  hours,  on  the  sheath  of  the  penis,  at  its 
base  or  around  it,  a  large,  deep  red  placard ;  swollen,  oedematous 
and  very  painful.    The  temperature  rises  to  40°  or  41°  C.  and  gen- 


Flg.  184.     Spontaneous    gangrene.      (Gfmy's    patient.) 


eral  symptoms  soon  appear:  dyspnoea,  nausea,  vomiting,  sometimes 
foetid  diarrhoea,  intense  thirst,  delirium  and  prostration.  The  local 
symptoms  increase  from  hour  to  hour,  the  sore  extends,  and  in  two 
or  three  days  the  whole  of  the  sheath  of  the  penis,  the  scrotum  and 
hypogastrium  are  invaded,  while  the  centre  of  the  lesion  becomes 
greenish  black  and  sloughing. 


THE    SHEATH    Ol^    THE    PENIS.  429 

The  slough  is  soft  and  melted  in  sanious  liquid  of  a  horrible  odour. 
During  this  time  the  process  increases  and  appears  to  be  rapidly 
approaching  a  fatal  termination,  when  suddenly  all  is  arrested,  and 
a  line  of  demarcation  forms  between  the  healthy  tissue  and  the  gan- 
grenous parts.  The  slough,  eliminated  by  the  sanious  fluid,  or 
removed  in  pieces,  is  replaced  by  granulation  tissue.  The  repair  of 
this  extensive  loss  of  substance  takes  place  with  extraordinary 
rapidity  and  in  i,  2  or  3  months  it  is  completed  without  much  cica- 
tricial contraction,  and  with  a  remarkable  preservation  of  the  forma- 
tion of  the  region. 

In  a  case  of  this  kind  the  streptococcus  literally  swarms  in  ex- 
tempore preparations.  Spontaneous  gangrene  would  thus  appear 
to  be  a  gangrenous  erysipelas.  In  other  cases  where  there  is  sub- 
cutaneous crepitation  its  extension  may  be  accompanied  by  prolif- 
eration of  the  anaerobic  microbes  which  have  been  studied  by  Veil- 
Ion  in  similar  cases. 

Treatment  is  at  first  entirely  surgical,  by  free  incisions,  drainage 
and  irrigation.  This  should  be  repeated  if  extension  of  the  lesion 
occurs.  During  the  period  of  repair,  sub-carbonate  of  iron  ( i  in  40) , 
in  the  form  of  powder  or  ointment,  is  useful,  as  in  all  cases  of  ex- 
tensive ulceration. 


THE    SCROTUM.^ 


Erythema.  Oe- 
dema. Eczema 
of  the  newly 
born p.  43t 


In  the  study  of  this  region  I  shall  first  consider' 
(edema,  intertrigo,  erythema  and  eczema  zvhich  may 
be  observed  in  the  newly  born  after  digestive  dis- 
orders  

.    ,    .   the  cutaneous  mucous  patches  of  secondary^  Cutaneous     mu- 
syphilis  of  sucklings J      ecus  patches    .   p.  43i 

.    .    .   the  angiokeratoma  of  Mibelli,  zchich  may^ 

occur  in  adolescents   as  small,   multiple,   keratoticl^'^^^s'^^^^^^^^^^    °^ 

Mibelli p.  43i 

venous  ncez'i ) 

.    .    .   the  sebaceous  cysts  which,  in  this  region,^  ^ 

;  J     11     •  ^Sebaceous    oysts  .  p.  432 

accompany  juvemle  acne  and  chloric  acne  ...    .J 

/  shall  say  a  few  words  on  the  crablouse  para—\  .  . 

,  .  ,  ji    1  ii  ■  •  LParasitism P- 432 

site  which  may  affect  this  region J 

.    .    .  and   also    cutaneous    hydrargyrism,   which-\  Cutaneous       h  y  - 
too  often  follows  applications  of  grey  ointment  .    .  J      drargyrism  ...  p.  432 

/  shall  mention  the  epithelioma  of  the  scrotunH       . 

,     •       ,•                     .  r  Epithelioma  ....  p.  433 

seen  very  rarely  m  chimney  sweeps J     *  ^  ^^"^ 

Syphilis  of  the  adult  occurs  in  the  form  of  cutanc-^ 
ous  mucous  patches J^  P-433 

A  prurigo  of  the  scrotal  raphe  exists  in  neurotic'] 
subjects ^Scrotal  prurigo  .  .  p.  433 

Eczema   may   occur  consecutive   to  varicocele     .  Varicose  eczema  .  p.  434 
/  shall  conclude  by  a  rapid  survey  of  psoriasis  oflp      ■     ■ 
the  scrotum,  occurring  in  general  psoriasis  .    ■   -j 


OEDEMA.    INTERTRIGO.     ECZEMA    OF    SUCKLINGS. 

The  normal  urine  has  little  tendency  to  create  traumatic  derma- 
titis in  the  suckling;  but  urine  and  foeces  during  enteritis  soon  be- 
come irritating.  A  red  dermatitis  follows  which  begins  around  the 
anus  and  extends  to  the  scrotum  and  groins.  It  is  accompanied  by 
slight  oedema  of  the  scrotum,  which  is  of  no  importance. 

Treatment  is  that  of  the  gastro-intestinal  disorder  which  is  the 
primary  cause  of  the  cutaneous  affection.     Local  treatment  in  cases 

of  acute  dermatitis  consists  in  the  application  of  emollient  cata- 
plasms (potato  starch,  etc.)  and  simple  zinc  paste.  Lycopodium  pow- 
der should  be  applied  freely,  to  avoid  direct  contact  with  urine  and 
foeces.    The  linen  should  be  changed  every  time  it  is  soiled. 

1  For  affections  common  to  both  scrotum  and  groin :  trichophytosis, 
erythrasma,  etc.,  vide  Inguinal  region,  p. 


THE    SCROTUM. 


431 


CUTANEOUS  MUCOUS  PATCHES  IN  INFANTS. 
In  the  suckling,  affected  with  secondary  syphillis,  the  papules  be- 
come superficially  exulcerated,  slightly  exudative  and  form  what 
are  incorrectly  termed  cutaneous  mucous  patches.  They  are  espe- 
cially numerous  around  the  anus  and  scrotum,  which  may  present 
10  or  20  of  them.  In  this  case  the  number  of  sores  renders  the  re- 
gion very  sensitive.  Apart  from  general  treatment  for  syphilis  local 
treatment  is  the  same  as  for  intertrigo,  described  above. 

ANGIOKERATOMA    OF    MIBELLI. 

This  lesion  is  usually  seen  on  the  back  of  the  fingers  and  hands 
(P-  338)  ;  its  localisation  on  the  scrotum  is  exceptional.  It  mani- 
fests itself  as  a  multitude  of  small,  purple,  venous  naevi,  dis- 
seminated on  a  rough,  slightly  pigmented  surface.  In  the  two  cases 
which  I  have  observed  the  scrotum  was  covered  with  a  hundred 
or  two  hundred  distinct  lesions,  and  the  eruption  extended  to  the 
'lower  abdomen  and  the  root  of  the  penis. 

Treatment 
is  by  galvano 
puncture  of 
each  nsevus 
and  gives  ex- 
cellent results. 
The  clinical 
relati  o  n  s  h  i  p 
o  f  angiokera- 
matoma  with 
erythema  per- 
nio, chilblain, 
etc.,  is  definite. 
A  1 1  methods 
formerly  em- 
ployed in  so- 
called  strum- 
ous affections 
may  be  util- 
ised; such  as 
cod-liver  o  i  1, 
residence  at 
the    seaside. 

Tig.  185.     Chloric    Acne. 
(Hallopeau's    patient.     St.    Louis    Hosp.    Museum,    No.    2139.)      CtC. 


432  THE    SCROTUM. 

SEBACEOUS    CYSTS. 

Sebaceous  cysts,  of  the  type  described  in  the  sheath  of  the  penis 
(p.  425),  may  be  met  with  in  the  scrotum,  in  more  or  less  abun- 
dance and  in  different  degrees  of  development.  They  are  especially 
seen  in  chlorine  workers  (vide  p.  236). 

PARASITISM. 

The  invasion  of  pediculi  pubis  may  cover  the  scrotum  with 
"crabs"  and  "nits."  In  average  cases  the  nits  are  first  seen  as 
small  shiny  spots,  and  blue  maculae  are  found  disseminated  on  the 
root  of  the  thigh  and  the  neighbouring  parts. 

The  "crab"  appears  as  a  grey  spot  with  apparently  a  crenated 
border.  It  is  fixed  to  the  hairs  by  its  four  claws  and  lies  flat  on 
the  skin  and  adherent  to  it.  A  certain  amount  of  practice  is  re- 
quired to  perceive  them. 

In  cases  where  there  are  only  a  few  lice  epilation  of  the  parasites 
and  hairs  bearing  the  eggs,  is  one  of  the  simplest  methods,  when 
performed  by  a  professional  epilator. 

A  more  expeditious  method  is  that  of  the  application  of  puri- 
fied xylol.  This  benzine  causes  much  smarting  of  the  skin  and 
the  application  should  not  last  more  than  2  or  3  minutes.  All  the 
parasites  and  the  eggs  are  destroyed  instantaneously.  There  is  a 
risk  of  slight  traumatic  dermatitis,  but  this  is  avoided  by  the  im- 
mediate application  of  oxide  of  zinc  ointment.  This  is  less  an- 
noying than  the  cutaneous  hydrargyrism  so  often  caused  by  the 
traditional  grey  ointment. 

CUTANEOUS   HYDRARGYRISM. 

It  is  not  uncommon  to  see,  in  the  out  patient  department  of  hos- 
pitals, a  patient  whose  scrotvim,  groins  and  lower  abdomen  are  of 
a  shiny  bright  red  or  purple  colour,  and  exfoliating  large  sheets 
of  epidermis.  The  patient  complains  of  intolerable  heat  and  smart- 
ing, and  is  often  ignorant  of  the  cause  thereof.  He  has  had  "crabs" 
and,  according  to  custom,  has  applied  a  thick  layer  of  grey  ointment 
to  the  whole  region  for  24  hours,  and  incompletely  washed  it  off. 
The  following  day  the  eruption  appears. 


THE    SCROTUM.  433 

If  the  grey  ointment  still  remains,  it  must  be  removed  by  soap- 
ing with  a  badger  hair  brush,  followed  by  alkaline  and  starch  baths, 
oxide  of  zinc  paste  or  carron  oil  liniment. 

In  spite  of  the  grey  ointment  the  lice  often  persist  on  the  lower 
abdominal  and  sacral  regions ;  on  the  chest  and  in  the  axillse. 


CHIMNEY-SWEEP'S    CANCER. 

This  disease  is  rare  and  tends  to  become  more  so.  It  may  oc- 
cur in  the  child  or  adolescent,  on  the  scrotum,  in  the  form  of 
a  vegetating  epithelioma  consisting  of  a  raised  placard,  of  slow 
and  relatively  benign  evolution.  In  the  single  case  which  I  have 
observed,  the  epithelioma  had  undergone  calcareous  change  and  ap- 
peared full  of  chalk,  some  of  which  resembled  gouty  tophi.  The 
severity  of  this  form  of  epithelioma  is  very  variable  and  cannot 
be  foretold.  Treatment  should  consist  in  scraping  with  the  curette 
and  radiotherapy. 

SECONDARY    SYPHILIS. 

In  individuals  whose  personal  cleanliness  is  neglected  and  who 
present  a  florid  secondary  syphilis,  the  more  or  less  abundant  papu- 
lar eruption  in  these  regions  may  become  ulcerative,  exudative  and 
somewhat  pruriginous.  These  lesions  should  be  treated  by  soap- 
ing twice  a  day  and  the  application  of  equal  parts  of  oxide  of 
zinc,  vaseline  and  lanoline ;  also  a  powder  of  equal  parts  of  talc 
and  oxide  of  zinc.  The  scrotum  may  be  separated  from  the  thighs 
by  a  sheet  of  dry  wool  powdered  with  the  same,  and  a  suspensory 
bag  may  be  worn. 

PRURIGO. 

This  affection  occurs  in  neurotic  and  overworked  persons.  It 
manifests  itself  at  first  by  extremely  severe  nocturnal  itching.  Later 
on  pruritus  occurs  in  the  day-time  and  increases  in  intensity  and 
in  extent  of  surface,  affecting  the  anal  and  intergluteal  regions. 
(See  pruritus  ani,  p.  450.) 

Prurigo  of  the  scrotum  is  situated  on  the  perineal  surface,  on 
and  around  the  raphe.  Eventually  a  lichenoid  state  is  formed,  with 
28 


434  THE    SCROTUM. 

a  g^ey  pigmented  placard  of  thickened  skin  resembling  morocco 
leather. 

The  itching  may  be  relieved  but  not  cured  by  zinc  paste,  or 
the  following  application : — 

Tartaric  acid "i  "j 

Resorcine laa  30  centigrammes  Igr.  2  to  3 

Menthol J  J 

Glycerole  of  starch  ....  60  grammes  ^i 

High  frequency  currents  and  radiotherapy  (3  units  H)  have  a 
good  effect  on  the  pruritus.  Rest  and  mountain  air  should  also 
be  prescribed. 

VARICOSE   ECZEMA. 

Varix  of  the  cord,  or  varicocele,  may  become  the  source  of  a 
chronic  cutaneous  irritation,  which  requires  careful  treatment. 
The  dartos  is  always  relaxed ;  the  testicles  pendulous ;  the  skin 
smooth,  soft,  and  moist,  red  and  pruriginous.  This  condition  is 
nearly  always  complicated  by  intertrigo  of  the  groin,  and  after 
scratching,  by  eczematisation  with  exudation  and  crusts. 

The  parts  should  be  painted  daily  with  tincture  of  iodine  (20 
per  cent),  followed  by  simple  ointment  and  powder. 

In  severe  cases  sweet  oil  of  almonds  may  be  applied  on  ab- 
sorbent wool :  in  benign  cases  the  parts  should  be  soaped  every 
day.  A  suspensory  bag  should  be  worn,  and  I  have  seen  good 
results  from  an  india-rubber  ring  compressing  the  scrotum,  the 
skin  below  the  ring  becoming  contracted  and  less  soft. 


PSORIASIS. 

In  the  course  of  a  general  psoriasis,  patches  may  occur  on  the 
scrotum,  but  they  present  no  special  feature  except  great  tena- 
ciousness. 

But  in  cases  of  old  neglected  psoriasis  the  whole  surface  of 
the  scrotum  may  be  covered  with  confluent  psoriasis.  These 
cases  are  difficult  to  treat  and  of  bad  prognosis ;  they  are  always 
inflamed,  intensely  red,  perpetually  exfoliating,  very  pruriginous, 
and  sometimes  exudative.    The  best  application  is  a  solution  of 


THE    SCROTUM.  435 

chrysarobin  in  chloroform  (5  per  cent),  covered  with  traumaticin. 
The  elastic  pressure  of  the  traumaticin  may  possibly  diminish 
the  congestion.  Sometimes  chrysarobin  is  badly  tolerated,  and 
then  weak  oil  of  cade  ointment  diminishes  the  inconvenience,  if 
it  does  not  remove  the  lesions. 


VARIA. 

Cancers  of  the  testicle :  sarcoma,  epithelioma  of  the  epididymis 
will  not  be  dealt  with  in  this  book.  Erythrasma  has  been  studied 
on  page  265 ;  the  post-erosive  papular  syphiloid  of  Jacquet  on  page 
509;  vitiligo  on  page  461 ;  and  elephantiasis  on  page  311. 


THE   GENITAL    ORGANS    IN    WOMEN. 


Erythema.        Vul- 
var oedema  ...  p.  437 


The  complex  region  presents  for  consideration^ 
erythematous      and     intertriginous      lesions,     and 
oedema  of  the  labia,   consecutive   to  enteric  affec- 
tions  in    the   newly-born 

.    .    .  Also  epidemic  gonococcic  vulvitis  of  little^  ,_  ,   .  . 
girls jVulvitis P.43JI 

Urethritis,  vaginitis  and  metritis  do  not  find  a  |  Cutaneous  compli- 
place  here,  but  their  cutaneous  and  mucous  com-  I  cations  of  va- 
plications  tnust  be  considered |      ginal    discharges  p.  437 

.    .    .   especially    esthiomcnus,    an     exulcerative,\        ,. 
hypertrophic,  elephantiasic  affection  of  the  labia   -J     ^  •   •   •  P- 43 

We   shall  speak   of  vulvar,  palillomatous   vege-^ 
tations,    which    may    multiply    around    the    z/m/z'o,  I  Vegetations  .  .  .  .p.  438 
especially  during  pregnancy ) 

We  shall  next  say  a  word  on  bartholinitis,  which^ 
is    only    an    abscess,    usually    gonococcic,    of    the  L  Bartholinitis  ....  p.  439 
gland  of  Bartholin  in  the  labium  majus | 

Vulvar   herpes   will    be   studied   with    vesicular,  I 

pustular     or     exulccrative     lesions     grouped     "in  V  Herpes p.  439 

bouquet" J 

Then,    soft    chancres;     ulcerative,    suppurating,]^ 
multiple  and  sometimes,  but  rarely,  extensive  and  L  Soft  chancre  ...  p.  440 
phagedenic | 

The  initial  lesion  of  syphilis,  of  which   the  un- 1 
limited  induration  is  special  to  this  region,  r^'^wtVrj  iHard  chancre  .  .  .  p.  440 
recognition | 

Secondary  syphilis  forms  vulvar  mucous  patchcs^^lucous  patches. 
and   condylomata J      Condylomata    .  p.  441 

Diabetes  may  cause  pruritus,  erythema  and   ul-'\ 
ceration  of  the  vulva JD.abetides    ....  p.  441 

A  non-diabetic  pruritus  may  also  occur,  which  is 
sometimes  intense  and  difficult  to  treat 

.  .  .  and  an  intertriginous  erythema,  non-dia- 
betic, generally  accompanying  chronic  senile  inter- 
trigo of  the  inguinal  folds  and  transverse  fold  of 
the  hypogastrium 

In  conclusion  I  shall  say  a  few  words  on  psori- 
asis of  the  labia  majora,  which  may  present  pe- 
culiar characters 


0  T,       . 
r  Pruritus p.  443 


Intertrigo     of     the 
labia p.  442 

Psoriasis     of     the 
labia p.  443 


.  .  .  and  shall  only  mention  tuberculous  lupus,  epithelioma,  syphilitic 
gumma,  etc.,  zvhich  are  only  seen  rarely  in  this  region  and  which  have  no 
special  characters. 


THE    GENITAL    ORGANS    IN   WOMEN.  43jr 

INTERTRIGO.    VULVAR    OEDEMA    OF    THE    NEWLY-BORN. 

In  young  girls,  during  an  attack  of  enteritis,  a  cutaneous  ir- 
ritation often  occurs  from  contact  with  abnormal  foeces  and 
urine.  This  may  be  called  by  any  name,  but  is  obviously  of 
traumatic  origin.  The  skin  is  red  and  pruriginous ;  there  is  oede- 
ma of  the  vulva  and  sometimes  a  slight  creamy  purulent  exuda- 
tion between  the  labia. 

This  condition  requires  strictly  local  hygiene ;  frequent  starch 
baths,  irrigation  with  frequent  changes  of  linen,  after  every  dis- 
charge of  urine  or  foeces.  A  piece  of  gauze  impregnated  with 
oil  of  sweet  almonds  should  be  placed  between  the  labia.  The 
afifected  skin  should  be  covered  with  lime  liniment,  or  oxide  of 
zinc  ointment.  The  enteritis,  which  is  the  cause  of  the  affection, 
must  also  be  treated. 

GONOCOCCIC  VULVITIS. 

In  little  girls  an  acute  suppurative  vulvitis  often  occurs,  which 
microscopic  examination  shows  to  be  due  to  the  gonococcus.  It 
is  very  contagious  by  mediate  contact  and  may  be  conveyed  by 
means  of  sponges,  towels,  night-commodes,  basins,  thermometers, 
enemas,  etc.,  without  direct  transmission  or  criminal  connection. 
This  vulvitis,  which  rarely  extends  to  the  vagina,  may  be  cured 
by  irrigation  with  permanganate  of  potash  (i  in  3000).  It  is 
often  epidemic  in  nurseries  and  in  hospitals,  and  as  soon  as  a  case 
is  recognised  contagion  must  be  prevented. 

Any  case  of  conjunctivitis  must  be  watched  with  great  care 
and  treated  vigorously  from  its  onset.  However,  in  these  cases 
conjunctival  contagion  is  exceptional. 


URETHRITIS.     VAGINITIS.     METRITIS. 

Urethritis,  vaginitis  and  metritis,  by  their  chronic  discharges 
and  the  stagnation  of  pus  between  the  labia  majora,  may  deter- 
mine cutaneous  irritations  of  various  kinds,  but  of  undoubted 
traumatic  and  microbial  origin. 

In  certain  cases  of  purulent  metritis,  there  are  seen  on  the  inner 
surface  of  the  labia,  exulcerations  with  circinate  borders,  which 


438  THE   GENITAL    ORGANS    IN    WOMEN. 

are    soon    followed    by    cutaneous    hypertrophy    and    transformed 
in  situ  into  suppurating,  unhealthy  fungosities. 

These  lesions  disappear  when  the  causal  metritis  is  cured  with- 
out local  treatment :  the  latter  is  useless  by  itself.  The  causal 
treatment  belongs  to  the  domain  of  gynoecology.  Local  treat- 
ment comprises  applications  of  zinc  ointment,  to  prevent  con- 
tact of  pus  with  the  mucous  membrane  and  skin.  The  hyper- 
trophic lesions  may  be  treated  in  the  same  way  as  vegetations 
(p.  417). 

ESTHIOMENUS. 

In  my  opinion,  the  ulcerative,  hypertrophic,  elephantiasic 
esthiomenus  of  the  older  authors,  is  only  an  excessive  develop- 
ment of  the  lesions  described  in  the  preceding  article  and  due 
to  the  same  cause.  It  does  not  consist  of  gonoi  rhoeal  exulcera- 
tive  lesions,  as  has  been  stated,  nor  of  tuberculous  or  syphilitic 
.  lesions,  but  really  of  banal,  chronic  hypertrophic  lesions,  in- 
variably due  to  a  morbid  vaginal  secretion.  It  has  been  at- 
tributed to  the  general  health  of  patients,  to  dirty  habits,  etc. ; 
but,  it  is  necessary  to  insist  that  the  suppression  of  vaginal  dis- 
charges, which  always  exist  in  these  cases,  leads  to  spontaneous 
suppression  of  the  exulcerative,  hypertrophic  lesions,  and  more 
slowly  of  the  chronic  subjacent  lymphangitic  condition,  which 
causes  the  local  elephantiasis. 

It  must  also  be  borne  in  mind  that  all  forms  of  local  treatment, 
which  may  be  useful  as  auxiliaries,  fail  as  long  as  the  vaginal  dis- 
charge is  not  suppressed. 

VEGETATIONS. 

Vegetations  are  rare  in  women  in  general,  only  common  in 
prostitutes,  which  tends  to  verify  the  opinion  of  those  who  desig- 
nate   vegetations  under  the  name  of  "gonorrhoeal  warts." 

In  women,  as  in  men,  they  commence  as  small  papular  tumours, 
which  become  mammillated  and  then  digitated :  they  multiply 
and  form  a  multi-digitated  tumour,  somewhat  resembling  the 
head  of  a  cauliflower  This  vegetation  seems  to  give  rise  to 
others,  and  the  vulvar  orifice,  the  internal  surface  of  the  labia, 
the  fourchette  and  the  labia  minora  mav  soon  be  covered.    The 


THE    GENITAL    ORGANS    IN    WOMEN.  439 

vegetations  are  red  and  epidermised,  but  the  opposed  surfaces 
secrete  a  purulent,  microbial,  malodorous  liquid,  which  necessi- 
tates continual  and  scrupulous  personal  hygiene. 

The  influence  of  pregnancy  on  the  development  of  these 
growths  is  undoubted,  and  they  may  attain  an  enormous  size 
and  require  immediate  treatment.  Usually  they  diminish  after 
child-birth,  but  not  always. 

When  they  attain  large  proportions  they  should  be  removed 
by  curved  scissors  and  the  bleeding  surfaces  dressed  with  a  solu- 
tion of  antipyrin  (30  per  cent)  to  arrest  the  diffuse  haemorrhage. 

In  less  severe  cases,  or  to  complete  the  results  of  operation, 
the  same  methods  may  be  used  as  in  the  vegetations  in  males, 
viz. :  cauterisation  of  each  vegetation  with  crystals  of  chromic 
acid  jwith  care  to  avoid  the  neighbouring  skin ;  or  powdering  with 
the  following : 

Powdered  savin 

Salicylic  acid 

Talc 2  parts 


I  aa     I  part 


This  should  be  applied  twice  daily,  after  washing  with  liquor 
carbonis. 

BARTHOLINITIS. 

Abscess  of  Bartholin's  gland  forms  a  painful  swelling  in  one 
of  the  labia.  It  is  most  often,  but  not  always,  consecutive  to  a 
former  gonorrhoea,  often  of  old  standing.  The  abscess  develops 
like  an  acute  abscess  but  with  sub-acute  symptoms.  Simple  in- 
cision of  the  abscess  is  often  followed  by  recurrence,  and  it  may 
be  necessary  to  enucleate  it. 

HERPES. 

Vulvar  herpes  in  women  is  not  so  common  as  progenital  herpes 
in  men.  It  is  generally  situated  on  the  inner  surface  and  upper 
part  of  the  labium.  It  is  preceded  by  itching  and  smarting,  and 
appears  in  the  form  of  distinct  vesicles  which  often  coalesce,  giv- 
ing rise  to  a  single  ulceration  with  a  yellow  base,  of  polymicro- 
cyclic  form,  slightly  suppurative  and  accompanied  by  more  itch- 
ing and  smarting  than  pain. 


440  THE    GENITAL    ORGANS    IN    WOMEN. 

The  concomitance  of  the  periods ;  the  repetition  of  the  out- 
breaks; their  identity  in  situation  and  in  evokition ;  the  total 
evohition  in  lo  days,  inckiding  2  of  eruption,  6  of  maturity,  and 
2  of  retrogression,  confirm  the  diagnosis.  The  gland  of  herpes, 
which  is  painful,  must  not  be  mistaken  for  the  indicator  gland  of 
a  chancre. 

Herpes  may  resemble  a  soft  chancre,  but  not  a  syphilitic 
chancre. 

The  treatment  is  palliative. 

~  SOFT   CHANCRE. 

In  women,  soft  chancres  may  occur  on  all  parts  of  the  genital 
organs  and  preserve  their  usual  signs.  They  are  most  often  sit- 
uated in  the  fourchette,  or  on  the  labia  minora,  and  may  be  re- 
cognised by  their  multiplicity,  their  irregular  form  and  punched 
out  appearance,  their  red  border,  and  abundant  suppuration.  In 
doubtful  cases  inoculation  on  the  arm  will  settle  the  diagnosis. 

Local  irrigation,  and  dressings  of  iodoform,  tannoform,  or  sub- 
carbonate  of  iron  ointment,  generally  give  good  results. 

The  evolution  of  soft  chancres  must  be  carefully  watched  in 
a  pregnant  woman,  for  pregnancy  is  an  etiological  factor  in 
phagedena. 

In  such  cases  each  chancre  should  be  promptly  treated  with 
carbo-sulphuric  paste^ ;  with  prolonged  sitz  baths,  and  starch 
poultices  at  night,  applied  over  a  layer  of  antiseptic  ointment, 
such  as  the  sub-carbonate  of  iron  (i  in  40). 


HARD  CHANCRE. 

In  women,  the  hard  chancre  may  be  situated  in  any  part  of  the 
genital  organs,  but  is  most  common  on  the  inner  surface  of  the 
labia  majora.  It  presents  the  usual  characters ;  exulceration,  in- 
duration, indicator  gland,  etc. ;  and  has  the  same  evolution  as 
chancre  in  the  male.  One  distinctive  character  may  be  men- 
tioned, that  is  the  dimensions  of  the  induration  and  its  absence 

1  Translator's  Note.  Carbo-sulphuric,  or  Ricord's  paste,  consists  of 
strong  sulphuric  acid  and  willow  charcoal;  sufficient  of  each  to  form  a 
thick  paste. 


THE   GENITAL    ORGANS    IN   WOMEN.  441 

of  demarcation.  In  the  male  the  induration  resembles  a  cartilagi- 
nous disc  enclosed  in  the  skin ;  in  the  female  it  forms  a  hard 
cedema  occupying  two-thirds  of  the  labium  and  doubling  its  size. 
Moreover,  this  induration  persists  after  the  chancre  is  healed,  and 
may  be  felt  several  months  later. 

Sometimes  when  the  hard  chancre  occupies  one  of  the  natural 
folds  of  the  region,  it  may  assume  a  laminated  form,  which  may 
resemble  the  deep  ulceration  of  a  soft  chancre,  especially  at  the 
fourchette;  but  the  hard  chancre  never  suppurates,  while  the 
chancroid  is  always  suppurative. 

MUCOUS    PATCHES. 

Mucous  patches  of  the  vulva  appear  soon  after  the  roseola  and 
eruption  of  secondary  lesions.  They  may  be  few  or  numerous, 
small  or  large,  sometimes  confluent,  and  may  be  situated  on  the 
inner  surface  of  the  labia  majora  or  minora,  the  fourchette,  etc. 
They  are  characterised  by  their  red  oval  erosion,  in  the  form  of 
a  saucer,  with  grey  edges ;  and  by  their  concomitance  with  other 
secondary  cutaneous  lesions.  They  may  occur  in  multiple  crops, 
and  as  a  rule  the  first  is  the  most  extensive ;  but  one  or  two 
patches  are  as  dangerous  as  fifty,  with  regard  to  coitus.  Patients 
should  always  be  warned  of  the  contagious  nature  of  the  lesions. 

Local  dressings  should  never  be  neglected,  as  they  may  dimin- 
ish the  risk  of  contagion.  General  treament  should  be  intense  and 
carried  out  under  the  supervision  of  the  physician  as  far  as  possible. 

CONDYLOMATA. 

Secondary  syphilis,  especially  when  florid,  may  be  accom- 
panied by  secondary  papillomatous  condylomata,  in  the  ano- 
genital  region.  They  will  be  referred  to  in  dealing  with  the 
dermatology  of  the  anal  region  (p.  448). 

DIABETIDES. 

Diabetes  causes,  in  women  as  in  men,  pruritus,  erythema  and 
ulceration  of  the  genital  organs. 

The  pruritus  is  often  the  first  symptom,  or  may  appear  with 
erythema :  it  is  often  severe,  with  alternate  exacerbations  and 
remissions.     The  erythema  covers  the  labia  and  extends  beyond 


442  THE   GENITAL   ORGANS    IN   WOMEN. 

them.  The  two  labia  have  a  reddish  yellow  colour,  with  a  clearly 
defined  border. 

The  diabetic  ulcerations  are  generally  situated  between  the 
labia  majora  and  minora,  on  the  inner  surface  of  the  labia  majora, 
or  the  fourchette.  They  form  painful  and  pruriginous  exulcera- 
tions ;  irregular,  reddish,  crustaceous,  slightly  suppurative  and 
slow  in  evolution.  These  symptoms  in  a  woman  of  middle  age, 
rather  obese,  indicate  an  examination  of  the  urine  for  sugar. 

Local  treatment  is  limited  to  washing  after  each  micturition 
and  the  application  of  oxide  of  zinc  ointment  Vv^ith  carbolic  acid 
or  menthol  (i  per  cent)  ;  or  the  sub-carbonate  of  iron  ointment 
(i  in  40). 

The  general  treatment  of  diabetes  has  much  more  effect  on  the 
diabetides  than  any  local  treatment. 

VULVAR   PRURITUS. 

Vulvar  pruritus  is  the  homologue  of  pruritus  of  the  scrotal 
raphe  in  men,  and  may  be  due  to  various  causes,  such  as  over- 
work, diabetes,  or  excitability  of  the  nervous  system.  The  real 
causes  of  pruritus  are  obscure  and  we  are  ignorant  of  the  con- 
nection between  pruritus  and  prurigo,  and  between  the  latter  and 
eczema  (p.  546).  In  any  case  vulvar  pruritus  is  an  affection 
of  middle  age ;  it  may  be  severe,  or  moderate,  and  may  be  ac- 
companied by  irritative  lesions,  or  by  no  apparent  lesion  at  all. 
Sometimes,  as  in  scrotal  pruritus,  it  creates  a  state  of  limited 
hard  oedema,  with  lichenoid  transformation  of  the  skin  ("moroc- 
co leather  skin")  and  hyperpigmentation.  The  hair  may  be  worn 
away  by  scratching. 

Treatment  consists  in  the  frequent  application  of  Van  Swieten's 
liquor,  very  hot^ ;  or  tar  diluted  with  an  equal  quantity  of  lano- 
line.     The  X-rays  also  have  a  remarkable  antipruriginous  effect. 

SENILE    INTERTRIGO. 

Chronic,  senile  intertrigo  of  the  fold  of  the  hypogastrium  and 
the  inguinal  folds,  in  fat  women,  is  often  accompanied  by  vulvar 

1  Translator's  Note.  Van  Swieten's  liquor  contains  half  a  grain  of 
perchloride  of  mercury  to  the  ounce. 


THE   GENITAL    ORGANS    IN    WOMEN.  443 

intertrigo,  which  may  constitute  a  difficult  therapeutic  problem. 
There  is  oedema  and  redness  of  the  labia  with  intense  pruritus. 
The  labia  are  purple,  indicating  intense  congestion.  Therapeutic 
intolerance  is  absolute. 

The  urine  should  be  examined,  and  if  there  is  glycosuria  this 
should  be  treated.  If  the  pruritus  is  extreme,  an  X-ray  applica- 
tion should  be  given  of  3  units  H,  or  a  half  tint  of  the  radiometer 
X  of  Sabouraiid  anc?  Noire. 

Application  of  nitrate  of  silver  (i  in  20),  followed  by  simple 
ointment,  is  useful;  or  the  following  ointment: — 


Oil  of  cade 

Oxide  of  zinc 

Ichthyol 1  I 

Resorcine I    aa     I  gramme      I  3ss 

Oil  of  birch |  | 

Vaseline 

Lanoline 


■"1    aa     5  grammes     I  sj; 


\   aa  IS  grammes  1   Bi 


For  the  internal  treatment  of  non-glycosuric  patients  and  the 
study  of  chronic  senile  intertrigo,  (see  p.  264  and  268.) 


PSORIASIS. 


Psoriasis  may  cover  the  labia  majora  and  extend  round  the 
vulvar  orifice  in  a  form  which  is  homologous  with  the  scrotal 
psoriasis  in  men.  All  that  I  have  said  concerning  the  latter  is 
true  in  this  case  (p.  434)- 

Treatment  is  very  difficult,  and  this  form  of  psoriasis  is  very 
intolerant.  The  application  of  nitrate  of  silver  may  be  tried,  if 
there  is  an  eczematous  tendency;  or  chrysarobin  (i  in  20)  cov- 
ered with  traumaticin  if  the  psoriasis  is  very  dry;  but  in  this 
case  the  mucosa  should  be  protected  by  simple  ointment  from  the 
irritation  of  the  chrysarobin. 

VARIA. 

The  labia  majora  may  be  affected  by  tuberculous  lupus,  epi- 
thelioma and  tertiary  syphilis  (sclerous  or  gummatous)  ;  but  the 
lesions  in  this  situation  have  no  special  characters  and  only  require 
to  be  mentioned   (vide  esthiomemis,  p.  438). 


THE  ANUS. 

The  dermatological  pathology  of  the  anus  is  complex,  and  like 
that  of  many  other  regions  may  be  divided  into  chapters  accord- 
ing to  the  age  of  the  patient. 

I.  During  the  first  months  of  infancy  an  ana/1  Syphilis  of  suck- 
eruption  of  secondary  syphilides  tnay  occur  .    .    .J      lings P-.445 

The   suckling    zvith    enteritis   presents   anal   and\               .  . 
peri-anal  epidermatitis,  of  considerable  semeiolog-V^^^'^^^'^^^^    °^    ^"' 
ical  importance |      ^^''^'' P-445 

The  marginal  region  of  the  anus  often  presents^  Simple  polymor- 
a  polymorphous,  papular,  circinate  and  figured  der-  V  phous  derma- 
matitis,  very  syphiloid  in   appearance J       titis    ....  p.  446 

In  second  infancy  simph  anal  pruritus  often  oc-' 
curs,  connected  with  habitual  constipation  ....     Pruritus    of    oxy- 

.    .    .  and  a  parasitic  pruritus  due  to  the  presence        uris p.  446 

of  oxyuris  vermiciilaris 

II.  Other  lesions  may  occur  at  any  age  but  more 
commonly  in  adults,  such  as  haniorrhoids   .... 

.    .    .   hard  chancre Hard  chancre 

.   .    .  secondary  syphilides,  mucous  patches  and\  Secondary       syph- 

condylomata -.    .    .    .J       ilis p 

.    .    .   or  soft  chancre Soft  chancre  .  .  .  .  p 

.    .    .  which    is    sometimes    phagedenic   ....     Phagedena p 

1  Gonorrhoeal 
.    .    .  or  anal  lesions  consecutive  to  gonorrhoeal 

rectitis.    Although    these    belong    to   surgery,    they 

require   to   be   knoivn   by   the   dermatologist  .    .    . 


Haemorrhoids     .    .  p.  446 

447 

448 
448 
449 


titis  .... 

"Inflammatory 

stricture  .  . 


III. 


1  Idiopathi 
Pruritus  am |     ^.^^^     _    _ 


c    pru- 
.    .    .  p 


...    1  Anal   fissure  .   .  .  p 
Fissures,  chronic  intergluteal  eczema;  m  its  "O'l  y  ^      1   te  1 
and  callous  form,  formerly  called  chronic  lichen   .  ' 


zema p 


450 
450 


450 
451 


451 
45^ 


Intertriginous    fissures    and    intertrigo    form    a] 
symptomatic  group  ivhich  is  common  and  t»i/>or/o«/ 1  Intertrigo  .... 
to  know;  more  common  in  middle  age I 

Ano-rectal    tertiary    syphilis;    often    called    ona/\ Rectal          syphilitic 
stricture J      stricture P- 452 

Ano-rectal  cancer Ano-rectal  cancer  p.  453 


THE   ANUS.  445 


Anal  tuberculosis  and  fissure;  very  polymorphous 
and  often  the  cause  of  serious  diagnostic  errors. 
By  this  resume  the  importance  of  the  dcrmatolog- 
ical  pathology  of  this  region  is  apparent 


"  Anal  fistula  ....  p.  453 
Warty      tuber- 

culosis p.  454 

Ulcerative      tuber- 
culosis   p.  454 

Lupus p.  456 

Circinate         tuber- 
culides    p.  456 

Ano-rectal      tuber- 
culosis   p.  456 


ANAL      AND      PERI-ANAL      SECONDARY      SYPHILIDES      OF 

SUCKLINGS. 

These  lesions  are  seen  in  infants  whom  hereditary  syphilis  has 
already  reduced  to  the  well-known  type  of  the  little  old  man,  with 
wrinkled,  flabby  skin,  too  large  for  the  body  it  covers ;  or  they  may 
occur  in  apparently  normal  infants,  who  seem  to  have  escaped  the 
influence  of  the  syphilitic  virus.  The  gluteal  region  is  more  or  less 
covered  with  secondary  elements  of  the  type  of  the  "cutaneous 
mucous  patch"  ;  i.e.,  the  secondary  exulcerated  papule,  slightly  raised, 
moist  and  sometimes  bistre  coloured. 

These  lesions  are  often  more  numerous  near  the  anus,  where  they 
are  found  in  the  radiating  folds.  They  may  be  confluent  and  are 
then  hypertrophic  and  almost  condylomatous. 

On  examination  of  the  body  a  similar  eruption  is  found  on  the 
face,  the  eyelids  and  the  buccal  commissures.  Corroborative  evidence 
and  examination  of  the  parents  and  the  nurse  support  an  uncertain 
diagnosis. 

Treatment  by  careful  administration  of  Van  Szinetoi's  liquor  (p. 
)  ;  exclusive  milk  diet,  by  the  maternal  milk  if  possible,  if  not  by 
goats'  or  asses'  milk,  or  cows'  milk  diluted  with  boiled  water  accord- 
ing to  age ;  finally,  suppression  of  suckling  by  a  nurse  when  she  is 
supposed  to  be  healthy,  and  careful  supervision  of  this  nurse,  are  the 
measures  to  be  adopted. 

ANAL   EPIDERMATITIS    OF   INFANTS   WITH    ENTERITIS. 

One  of  the  best  signs  of  enteritis  in  infants  is  anal  and  peri-anal 
epidermatitis.  In  the  most  simple  and  most  concealed  cases,  sepa- 
ration of  the  anal  folds  shows  a  redness  and  a  slightly  fissured  con- 
dition, causing  very  little  discomfort.  In  more  severe  cases  there  is 
intergluteal  eczema  and  erythema  of  the  margin  of  the  anus  with  an 
intertriginous  state  of  the  inguinal  or  scrotal  regions. 


446  THE    ANUS. 

This  condition  may  set  up  a  more  or  less  exudative  eczematisation 
of  these  regions  and  of  the  surrounding  parts.  The  general  eczema 
which  follows  or  accompanies  digestive  troubles  in  infancy  usually 
commences  on  the  face. 

Local  treatment  consists  in  scrupulous  cleanliness,  baths  and  oint- 
ments of  oxide  of  zinc  and  vaseline  ( i  in  3),  and  lycopodium  powder. 

It  is  hardly  necessary  to  state  that  the  proper  treatment  of  these 
eruptions  is  intestinal  treatment, 

SIMPLE    POLYMORPHOUS    DERMATITIS    OF  INFANTS 
Figured    Erythema.         Post-Erosive    Circinate    Syphiloid    of  Jacquet 

In  a  great  number  of  cases  dermatitis  of  the  buttocks  in  infants 
take  a  special  form,  which  may  resemble  secondary  syphilides.  The 
simple  erythema  spoken  of  above  may  become  complicated  with 
superficial  erosive  lesions,  slightly  papular,  but  much  redder  and  less 
copper  coloured  than  syphilitic  lesions ;  they  are  often  disseminated 
on  a  diffuse  erythematous  base  and  diminish  in  number  on  the  but- 
tocks, thighs,  flanks  and  hips,  in  proportion  to  the  distance  from 
the  anus.  The  eruptions  are  polymorphous,  because  they  consist  of 
lesions  in  different  stages  and  are  accompanied  by  itching  and  smart- 
ing. They  appear  to  be  abortive  lesions  of  impetigo  grafted  on  ery- 
thema. They  will  be  referred  to  again  with  the  region  of  the  but- 
tocks. 

Treatment  consists  in  lotion  of  sulphate  of  zinc  (i  per  cent)  and 
ointment  of  oxide  of  zinc.  Soaping  and  irritating  antiseptics  should 
be  avoided. 

ANAL    PRURITUS    WITH    OXYURIS    VERMICULARIS. 

This  is  apparently  a  somewhat  rare  affection,  for  I  have  only  seen 
it  twice.  The  anus  is  the  seat  of  perpetual  itching  and  the  skin 
is  red  and  desquamating,  with  macerated  epidermis  in  the  folds. 
Small  round  worms  are  frequently  seen  to  escape  from  the  anus,  and 
the  child  scratches  at  night. 

Treatment  consists  in  sulphate  of  quinine  lotion  and  the  following 
ointment  to  the  anus : — 

^nnin 1  aa  30  centigrammes     j.  gr,  S 

Calomel J  J 

Vaseline 30  grammes  5i 


THE    ANUS.  447 

HAEMORRHOIDS, 

Haemorrhoids  occur  in  both  sexes  and  at  all  ages.  In  their  usual 
form,  the  only  one  for  which  a  dermatologist  is  consulted,  they  con- 
sist of  small  tumours  the  size  of  half  a  cherry,  soft  and  emptied  by 
pressure  and  swelling  up  with  the  least  effort.  The  colour  is  that 
of  the  neighbouring  skin,  for  they  are  formed  by  deep  varices  and 
are  not  intra-cutaneous  or  immediately  sub-cutaneous.  Sometimes 
one  or  more  of  these  tumours  occurs  in  the  radiating  folds;  some- 
times one  projects  from  the  anus.  Also  internal  hsemorrhoids  may 
emerge  during  an  effort.  The  painful  symptoms  vary,  but  are 
especially  marked  during  defecation  and  when  there  is  constipation. 
Haemorrhage  is  seldom  abundant  or  frequent ;  it  occurs  during  defe- 
cation. 

Haemorrhoids  appear  and  disappear,  and  only  serious  cases  require 
surgical  intervention.  They  should  be  treated  with  local  cold  bath- 
ing at  night  and  ointments  containing  belladonna,  etc. 

ANAL    SYPHILIDES.    HARD    CHANCRE. 

Hard  chancre,  mucous  patches,  ulcerated  papules  and  condylomata, 
the  syphilitic  nature  of  which  is  not  determined,  but  which  accom- 
pany secondary  florid  syphilides,  especially  in  women,  may  all  occur 
about  the  anus. 

Hard  chancre  is  generally  situated  in  the  anus  itself,  on  a  fold  of 
the  anal  orifice.  It  presents  the  usual  characters;  induration,  exul- 
ceration,  absence  of  suppuration,  and  spontaneous  cure.  It  is  very 
often  mistaken  for  a  hsemorrhoid  by  the  patient,  and  too  often  also 
by  the  physician.  It  is  usually  single  and  the  indicator  ganglion  is 
situated  near  the  antero-superior  iliac  spine,  in  the  external  group  of 
inguinal  glands.    It  requires  no  special  local  treatment. 

MUCOUS   PATCHES. 

Mucous  patches  are  generally  disposed  in  the  radiating  folds ;  they 
vary  in  number  and  may  be  discrete  or  confluent.  Diagnosis  from 
soft  chancres  is  made  by  the  absence  of  the  sloping  borders  and  sup- 
puration of  the  chancroid,  the  co-existence  of  secondary  cutaneous 
or  mucous  syphilides  in  other  places,  polyadenitis,  etc. 

Local  treatment  by  nitrate  of  silver  gives  the  same  results  here  as 
elsewhere  and  the  general  treatment  presents  nothing  peculiar. 


448  THE   ANUS. 

SECONDARY  SYPHILITIC  PAPULES. 

These  often  occur  at  the  margin  of  the  anus  in  an  exulcerated 
form.  These  papules  project  for  i  or  2  millimetres  and  are  often  3 
or  4  millimetres  wide.  They  sometimes  preserve  their  epidermis  and 
are  then  brownish  or  ham  coloured;  but  they  are  often  exulcerated 
like  the  chancre,  and  moist  but  not  discharging. 

In  persons  with  dirty  habits  these  cutaneous  mucous  patches  may 
attain  an  extreme  degree  of  confluence,  not  only  in  the  peri-anal 
region,  but  in  the  whole  inguino-vulvar  and  ano-vulvar  regions. 
This  condition,  in  its  highest  degree  of  confluence  and  filthiness,  is 
seen  in  women.  There  is  maceration  of  the  epidermis  of  the  folds 
and  intertriginous  epidermatitis ;  and  it  is  in  these  cases  that  condy- 
lomata develop. 

The  treatment  of  exuberant  secondary  syphilides  comprises  baths, 
cauterisation  with  nitrate  of  silver,  and  the  application  of  oxide  of 
zinc  ointment,  and  zinc  and  talc  powder. 


CONDYLOMATA. 

Condylomata  are  raised,  pedunculated  growths,  of  semi-solid  con- 
sistence, polygonal  in  form  by  pressure  of  the  buttocks,  between 
which  they  develop.  They  are  digitated,  velvety,  almost  papillo- 
matous, pink,  incompletely  epidermised  and  exudative.  They  appear 
to  develop  by  maceration  of  the  syphilitic  lesions  described  above, 
for  they  are  always  seen  under  those  conditions.  When  first  seen 
they  are  bathed  in  pus  which  covers  the  exulcerated  epidermis,  and 
the  mixture  of  lesions  exhales  an  infectious  odour. 

Washing  with  soap  and  the  application  of  pastes  and  powders  may 
cause  the  condylomata  to  disappear,  but  it  is  simpler  to  remove  them 
with  scissors  and  cauterise  the  base  with  nitrate  of  silver,  followed 
by  the  applications  mentioned  above   (p.  439). 

In  a  few  days  the  lesions  are  restored  to  those  of  simple  secondary 
syphilis. 

SOFT  CHANCRES. 

Soft  chancres  of  the  anus  are  not  uncommon ;  they  are  always 
multiple,  often  radiating  in  the  skin  folds. 


THE   ANUS. 


449 


The  chancres  are  generally  5  to  10  millimetres  long  by  3  or  4  in 
width,  and  punched  out  to  the  depth  of  i  or  2  millimetres.  Each 
has  a  sinuous  border  with  a  red  margin.  The  base  is  covered  with 
an  adherent  layer  of  pus,  which  is  not  removed  by  cleaning  the 
ulcer. 

The  chancres  may  be  reinoculated  more  or  less  in  the  anal  region 
and  on  the  adjacent  surfaces  of  the  buttocks.     They  may  cause  a 


Figr.  186.     Simple  multiple  chancre  of  the  anus. 
(Fournier's  patient.     St.   Louis  Hosp.   Museum,   No.   647.) 


glandular  chancre  of  the  groin,  like  chancroids  of  the  vulva  and 
penis. 

Treatment  is  the  same  as  for  chancroid  of  the  penis.  A  tampon 
may  be  placed  in  the  anus,  soaked  in  iodoform  ointment  (lo  per 
cent)  ;  or  sub-carbonate  of  iron  (i  in  40)  ;  or  cinnabar  (i  per  cent). 

PHAGEDENIC  CHANCRE. 

Phagendenic  chancre  is  never  an  indurated  chancre;  it  may  be  a 
mixed  chancre  or  more  often  a  chancroid.^ 

^  Translator's   Note.     It   is   true   that   the   phagedenic   chancre   is  not 
typically  indurated;  but  it  is  usually  followed  by  secondary  syphilis. 
29 


450  THE    ANUS. 

Phagedena  is  usually  observed  in  pregnant  women,  or  under  local 
conditions  of  filth ;  sometimes  without  any  perceptible  cause.  Care- 
ful cleansing  with  camphorated  ether,  or  oxygenated  water  and 
dressing  with  sub-carbonate  of  iron  ointment  ( i  in  40) ,  are  gen- 
erally sufficient  to  arrest  the  commencing  phagedena.  If  not,  the 
X-rays  may  be  tried  (6 -units  H  of  the  radiometer  X),  at  intervals 
of  20  days ;  but  at  present  there  is  no  certainty  in  their  value. 

GONORRHOEAL   RECTITIS. 

Acute  gonorrhoeal  rectitis  is  rare,  but  may  occur  in  concomitance 
with  one  or  other  of  the  preceding  lesions.  The  diagnosis  is  certi- 
fied by  the  presence  of  the  gonococcus  in  the  pus.  It  its  chronic 
state  it  may  lead  to  proliferating  rectitis  and  to  inflammatory  stric- 
ture. 

Treatment  belongs  to  the  surgeon  rather  than  the  dermatologist. 
Rectal  irrigation  with  permanganate  ( i  in  5000)  may  be  prescribed. 

ANO-RECTAL   INFLAMMATORY  STRICTURE. 

There  exists  a  chronic  proliferating  rectitis,  which  covers  the  rec- 
tal mucosa  with  bleeding  fungosities.  This  condition,  which  is  pri- 
m.arily  of  gonorrhoeal  origin,  is  not  a  dermatological  affection  and  is 
beyond  the  scope  of  this  work.  It  may,  however,  determine  a  derma- 
titis of  the  intergluteal  fold,  which  will  be  dealt  with  later  (p.  451). 

PRURITUS  ANI. 

There  is  an  anal  pruritus,  which  is  called  idiopathic  because  the 
cause  is  unknown  and  because  it  occurs  without  any  lesion  of  a 
definite  nature.  The  pruritus  is  intense  and  occurs  in  crises,  espe- 
cially at  night,  leading  to  severe  scratching.  The  scratching,  which 
often  causes  erosions,  provokes  a  quasi-voluptuous  sensation  and 
relieves  the  itching  for  a  time. 

Examination  of  the  region  often  reveals  a  macerated  whitish  epi- 
dermis, somewhat  thickened  and  striated  with  concentric  marks,  due 
to  epithelial  debris  in  the  radiating  folds. 

When  the  pruritus  exists  only  at  the  anus  the  best  treatment  con- 
sists in  the  local  application  of  pine  tar,  either  pure  or  diluted  with 


THE    ANUS.  451 

lanoHne  or  oleum  theobroma;.  These  applications  often  cause  smart- 
ing, but  relieve  the  itching  immediately,  and  cause  a  permanent  cure 
in  many  cases. 

When  the  pruritus  is  generalised  the  same  preparations  may  be 
used,  but  general  treatment  by  high  frequency,  or  X-rays,  is  neces- 
sary. 

ANAL   FISSURE. 

Anal  fissure  is  a  complication  of  diverse  morbid  conditions;  rec- 
titis,  anal  eczema,  pruritus  ani,  etc.  It  is  seldom  seen  except  in 
neurotic  subjects.  The  fissure  may  gradually  become  of  considera- 
ble dimensions  and  depth;  but  it  is  often  minute  and  hidden  in  the 
anal  folds. 

The  fissure  causes  a  reflex  constriction  of  the  anus,  which  is  much 
more  painful  than  the  fissure  itself.  Immediate  treatment  is  required. 
Formerly  forced  dilatation  under  chloroform  was  practised,  but 
faradisation  is  often  sufficient. 


ECZEMA  OF  THE  INTERGLUTEAL  FOLD  AND  ANUS. 

Cases  occur  where  anal  pruritus,  with  all  the  characters  described 
above,  is  observed  at  the  same  time  as  a  chronic  eczema  of  the  inter- 
gluteal  fold.  The  latter  occupies  the  fold  from  the  anus  to  the 
end  of  the  sacrum,  and  even  extends  onto  the  sacral  region,  where 
it  forms  one  or  two  red,  raised  placards,  of  chronic  duration  and 
constituting  a  marked  induration  covered  with  white  psoriasiform 
scales.  At  other  times  the  placards  are  lichenised,  papular,  par- 
quetted,  with  a  shiny  flat  surface,  and  divided  into  lozenge  shaped 
areas  by  dry,  non-fissured  lines. 

This  lesion  extends  with  the  same  characters  up  to  the  arms, 
sometimes  as  an  indurated  lesion  occupying  the  intergluteal  fold, 
sometimes  as  a  flat  laminated  lesion  with  a  fissure  in  the  inter- 
gluteal fold. 

The  anal  lesion  is  that  which  we  have  described  in  idiopathic  pru- 
ritus. The  treatment  is  also  the  same.  Treatment  of  the  eczematous 
lesions  of  the  fold  and  of  the  sacral  region  is  difficult.  The  best 
results  are  obtained  with  compound  oil  of  cade  ointments: — 


Ichthyol  .  . 
Resorcine  . 
Oil  of  fcirch 


.    aa     I  gramme     U    gr.  2i2 


452  THE   ANUS. 

Oil  of  cade 1   aa  15  grammes 

Lanohne   J 


}^' 


In  more  severe  cases  more  active  measures  may  be  employed,  such 
as  quadrilateral  scarification,  double  cauterisation  with  two  crayons 
of  nitrate  of  silver  and  metallic  zinc,  etc. 

These  lesions  often  occur  in  feeble  and  constipated  subjects,  and 
the  treatment  of  the  constipation  is  indispensable,  combined  with  a 
generous  diet. 

INTERTRIGO  OF  THE  INTERGLUTEAL  FOLD. 

Intertrigo,  which  is  common  on  this  region  in  sucklings,  also 
occurs  in  the  adult ;  either  as  a  simple  intertrigo  accompanying  a 
similar  condition  of  the  inguino-scrotal  or  vulvar  regions,  or  as  a 
complication  of  an  eczematous  state,  of  the  type  which  we  have  just 
described.  In  the  latter  case  the  treatment  of  the  intertriginous 
fissures  is  blended  with  that  of  the  eczematous  placards  between 
which  they  occur.  They  may  also  be  treated  separately,  by  cauterisa- 
tion, or  by  daily  painting  with  friar's  balsam. 

In  simple  intertrigo,  treatment  is  the  same  as  that  recommended 
for  inguinal  intertrigo ;  soaping,  daily  friction  with  weak  alcoholic 
solutions  of  iodine  and  coaltar,  or  ichthyol  (10  per  cent)  are  some 
of  the  most  simple  and  the  best  methods  of  treatment.  Active  meas- 
ures are  only  required  in  more  intense  cases;  application  of  nitrate 
of  silver  (i  in  5  to  i  in  15)  ;  tincture  of  iodine  (i  in  3  to  i  in  10; 
pastes  or  powders. 

SYPHILITIC  STRICTURE. 

Syphilitic  stricture  of  the  rectum  is  a  tertiary  lesion ;  according  to 
some,  quaternary  because  it  may  occur  30  years  or  more  after  the 
initial  lesion.  It  is  situated  above  the  anus,  which  is  not  affected.  It 
consists  in  a  progressive  stenosis  produced  by  a  ring  of  neoplastic 
tissue  tending  to  fibrous  transformation  ;  its  evolution  lasts  for  years. 

It  occurs  especially  in  women  and  manifests  itself  by  progressive 
obstruction,  occurring  in  crises,  which  may  render  colotomy  neces- 
sary. 

Antisyphilitic  treatment,  although  it  has  an  effect  on  the  lesion  in 
an  early  stage,  cannot  disperse  the  fibrous  tissue  when  it  is  once 


THE   ANUS.  453 

formed.  The  dermatologist,  under  these  circumstances,  can  only 
establish  the  diagnosis  and  institute  intensive  treatment,  and  when 
this  gives  no  result  must  have  recourse  to  the  surgeon. 

Under  the  title  of  rectal  syphiloma,  which  is  rare,  many  cases  of 
ano-rectal  tuberculosis  and  some  inflammatory  strictures,  simple  or 
post-gonorrhoeal,  were  formerly  confounded. 

Treatment  consists  in  weekly  injections  of  grey  oil  (p.  651)  and  15 
to  60  grains  of  iodide  of  potassium  daily.  Injections  of  oil  and  pur- 
gatives should  be  given  to  avoid  obstruction.  Local  treatment  is 
limited  to  the  use  of  antispasmodics  and  sedatives;  suppositories  of 
belladonna,  cocaine,  etc. 

ANO-RECTAL  CANCER. 

Cancer  of  the  ano-rectal  region  is  not  uncommon,  and  its  diagnosis 
from  simple  chronic  inflammatory,  syphilitic  and  tuberculous  lesions 
may  present  great  difficulties. 

Sometimes  it  is  a  schirrus  carcinoma  in  the  form  of  a  ring;  some- 
times a  lateral  epithelioma,  which  may  extend  towards  the  skin  and 
infiltrate  the  margin  of  the  anus;  epithelioma  in  sheets,  or  chorio- 
cpitheliomatosis  analogous  to  that  of  the  breast.  Lastly,  in  rare 
cases  Paget' s  disease  may  be  met  with  (p.  494).  In  this  case  only 
is  the  lesion  a  dermatological  one ;  and  we  shall  not  dwell  upon  the 
diagnosis  and  treatment  of  affections  which  are  essentially  surgical. 

ANO-RECTAL  TUBERCULOSIS, 

Anal  abscess.  Fistula.  This  morbid  type  may  occur  during  per- 
fect general  health,  and  this  is  the  most  common  event;  or  it  may 
occur  in  a  patient  with  pronounced  tuberculosis. 

At  sorne  distance  from  the  anus  a  swelling  appears  with  all  the 
characters  of  inflammation:  tumor,  rubor,  dolor,  color;  fluctuation 
is  felt  and  the  swelling  opened;  the  abscess  gradually  heals  like  an 
acute  abscess.  But  a  fistula  persists  which  discharges  a  drop  of  pus 
every  day ;  or  after  a  time  a  new  abscess  forms  with  the  same  symp- 
toms and  course,  at  a  variable  interval  after  the  first.  If  there  is 
diarrhoea,  foeces  may  pass  by  the  fistula. 

Exploration  of  the  fistula  with  a  director  shows  that  it  leads  into 
the  rectum.    With  the  finger  of  the  left  hand  the  end  of  the  director 


454 


THE   ANUS. 


is  brought  outside  and  the  fistula  converted  into  an  open  wound  with 
the  bistoury.  The  wound  is  then  cauterised.  When  the  fistula  has 
several  tracks,  or  orifices,  the  same  procedure  is  done  for  each.  A 
cure  generally  results,  but  recurrence  takes  place  if  one  of  the  tracks 
is  left  unopened. 

The  tuberculous  nature  of  common  anal  fistula  is  certain,  and 
clinical  experience  often  shows  that  anal  fistula  often  precedes  pul- 
monary tuberculosis.  This  warning  must  not  be  neglected,  and 
super-alimentation,  etc.,  should  be  advised. 

Anal  fistula  is  one  of  the  most  benign  forms  of  local  tuberculosis 
and  forms  a  connection  between  the  surgical  forms  of  tuberculosis 
of  this  region  and  those  which  more  specially  concern  the  derma- 
tologist. 

Hypertrophic,  W^arty,  or  Ulcerative  Cutaneous  Tuberculosis. 
— Occasionally  there  occurs,  either  at  the  orifice  of  a  fistula  or  at  the 
anal  orifice  itself,  a  tuberculosis  of  the  hypertrophic,  papillomatous 


Tig.  187.     Warty  tuberculosis  of  the   anus. 
(Morestin's  patient.      St.   Louis  Hosp.   Museum,   No.   2220.) 

type,  which  is  common  on  the  back  of  the  hand  and  the  foot,  and 


THE  ANUS.  4SS 

which  has  a  considerable  resemblance  to  secondary  syphilitic  condy- 
lomata of  this  region.  It  forms  cauliflower  growths,  varying  in  size 
and  number  and  not  pedunculated,  having  generally  a  base  as  large 
as  themselves.  Sometimes  the  surface  is  villous  and  divided  by  fur- 
rows, sometimes  formed  partially  by  a  soft  mass  of  fungosities. 

With  this  hypertrophic  form  must  be  placed  an  ulcerative  form 
which  is  not  well  known,  but  not  very  rare.  The  ulceration  arises 
at  the  anus  and  develops  laterally,  invading  one  of  the  buttocks.  This 
ulceration  is  deep,  with  a  lough  surface  and  a  grey  base,  sanious  or 


Fig.  188.     Tuberculous  ulceration  of  the   anus. 
(Martineau's  patient.     St.  Louis  Ho.sp.  Museum,   No.   311.) 


purulent  and  impossible  to  clean  completely.  The  border  is  thick, 
callous  and  indurated,  and  its  internal  surface  the  seat  of  incessant 
and  progressive  necrosis.  Pain  is  generally  slight  in  both  these 
forms,  except  when  the  ulceration  extends  to  the  anus  or  scrotum. 

The  ulcerative  form  is  much  more  grave,  and  extensive  surgical 
terisation  with  nitrate  of  silver  and  zinc.  If  intra-cutaneous  indu- 
ration remains  it  may  be  dealt  with  by  the  galvano-puncture. 

The  ulcerative  form  is  much  more  grave  and  extensive  surgical 
removal  should  be  preferred  whenever  possible,  with  strict  super- 


4S6  THE   ANUS. 

vision  of  the  wound  during  cicatrisation  and  immediate  cauterisa- 
tion of  any  doubtful  points  which  may  recur.  Apart  from  removal, 
the  ulcer  may  be  treated  with  the  galvano-cautery,  under  an  anaes- 
thetic. These  cases,  although  grave  and  of  rapid  development, 
heal  very  well.  I  have  several  times  seen  pieces  removed  sent 
for  examination  as  epithelioma.  The  error  is  avoided  by  simple 
bacteriological  examination,  for  the  nectrotic  border  of  the  ulcer 
swarms  with  turbercle  bacilli,  and  no  tuberculous  lesion  shows  more 
of  them. 

Lupus.  Tuberculous  lupus  may  occur  at  the  anus,  but  is  rare.  It 
has  no  peculiarities  in  this  region;  it  arises  at  the  anus,  and  is  gen- 
erally unilateral.  It  forms  a  chronic,  congestive,  circumscribed  patch 
of  oedema,  slightly  raised  above  the  skin.  Under  the  horny  epider- 
mis appear  disseminated  tubercles,  which  are  rendered  visible  by 
pressure  under  a  glass  slide,  which  diminishes  the  congestion  of  the 
neighbouring  tissues.  There  is  no  special  treatment  required ;  this  is 
the  same  as  for  lupus  of  the  face  in  its  first  stage :  viz.,  phototherapy ; 
and  when  this  is  impossible  the  galvano-cautery  at  regular  sittings. 
Tuberculous  lupus  of  this  region  does  not  usually  become  ulcerative. 

Extensive  circinate  Tuberculides.  Tuberculides  of  abnormal 
and  rare  types  are  met  with  in  the  region  of  the  anus  more  com- 
monly than  elsewhere.  These  eruptions  may  assume  diverse  forms, 
chiefly  that  of  a  large  and  almost  regular  circle,  with  a  red  border 
covered  with  small,  pink,  raised  disseminated  nodules.  The  circle, 
having  a  diameter  of  3  to  5  inches,  is  traced  on  one  buttock  and  is 
connected  with  the  anus  by  a  kind  of  prolongation.  This  lesion 
may  co-exist  with  others  of  the  same  nature,  scattered  here  and 
there  around  it.    The  treatment  is  the  same  as  for  lupus. 

Ano-rectal  Tuberculosis.  This  is  the  homologue  of  the  ano- 
rectal syphiloma  mentioned  above.  It  is,  however,  much  more  com- 
mon and  is  accompanied  by  the  same  functional  symptoms.  The 
evolution  is  analogous,  and  diagnosis  is  made  by  extirpation  and 
examination  of  a  fungosity;  or  by  direct  examination  of  the  glairy 
discharge  which  usually  occurs  in  concomitance  with  this  lesion. 
Treatment  is  surgical. 


THE  HYPOGASTRIC  REGION. 


Phtiriasis p.  457 

Scabies p.  459 


-  Pustulation 


P-459 


-Pityriasis    simplex  p.  460 


Pityriasis     rosea  .  p.  461 


.Psoriasis p.  461 


The  hypogastrium  presents  a  hairy  region,  the 
pubes,  where  a  special  pediculosis  occurs  .... 

Around  this  region,  scabies  forms  a  series  of 
lesions,  as  characteristic  as  those  on  the  hands  and 
Angers  

On  the  pubic  region  may  be  seen  acute  or  chronic 
pustules,  spontaneous  or  more  often  traumatic  (hy- 
drargyrism) 

Above  the  inguinal  regions  the  hypogastrium  may 
present  several  isolated  lesions  of  pityriasis  sim- 
plex, which  are  often  unrecognised 

A  localised  form  of  pityriasis  rosea  may  occur 
here,  with  normal  elementary  lesions;  circular  and 
pink;  abnormal  only  in  their  strict  localisation   .    . 

An  abnormal  psoriasis  sometimes  occurs  in  this 
region  only  or  in  conjunction  with  psoriasis  of  the 
scalp 

The  hypogastrimn  is  one  of  the  seats  of  election}     ....        ,,       ,  ^ 

,..,.,            ,  ^Vitiligo.  Morphoea p.  461 

of  vitiligo  and  morphoea -^ 

Alopecia  areata  is  rarely  localised  to  this  regiGn\ 

f  Alopecia  areata  .  .  p.  462 
only -' 

/  shall  conclude  zvith  intertrigo  of  the  horizontal 

fold  of  the  hypogastrium,  which  generally  develop sV\r\ttrir\g,o p. 462 

ivith  inguinal  intertrigo 

PEDICULOSIS. 

The  pubic  region  is  the  usual  seat  of  a  phtiriasis  caused  by  a 
special  louse;  the  crab-louse,  or  Pediculus  publis  (Fig.  189). 

This  parasite,  which  is  very  distinct  from  the  head  louse  and  the 
clothes  louse,  is  characterised  like  all  human  pediculi,  by  antennae 
with  5  joints,  and  feet  with  a  single  claw ;  but  while  in  the  lice  of 
the  body  and  head  the  thorax  is  narrower  than  the  abdomen;  in  the 
pediculus  or  phtirius  pubis  it  is  wider. 


4S8 


THE    HYPOGASTRIC    REGION. 


Fig.  189.     Pediculous     pubis.        (Photo,     by     Noirg.) 


Like  the  other  Hce,  it  is  reproduced  by  nits,  which  are  rather 
smaller  than  those  of  the  ordinary  louse,  but  of  the  same  shape  and 

glued  to  the  hair   in 

1     the   same    manner 

(Fig.  70) . 

The  crab-louse  is 
nearly  always  flat- 
tened and  glued  to 
the  skin,  hanging  on 
by  its  four  claws,  so 
that  removal  is  trou- 
blesome. It  is  very 
difficult  for  an  un- 
practised eye  to  per- 
ceive them,  for  they 
project  very  slightly 
and  only  appear  on 
the  skin  as  minute 
grey  spots  among  the 
hairs. 

It  is  discovered  by  the  grey  shiny  eggs  attached  to  the  base  of 
the  hairs  and  very  adherent  to  them.  When  the  pullulation  of 
the  parasites  has  been  considerable,  slate-blue  spots  are  seen  around 
the  pubis  and  on  the  thighs,  3  or  4  millimetres  wide,  which  corre- 
spond to  an  intoxication  of  the  skin  by  poison  introduced  by  the 
pricks  of  the  parasite.  It  is  possible  for  excessive  multiplication 
of  pediculi  to  provoke  a  staphylococcic  folliculitis,  but  this  is  rare. 
The  traditional  treatment  of  pediculi  with  grey  ointment  (nea- 
politan  ointment,  or  double  mercurial  ointment)  is  not  without 
inconvenience;  in  certain  skins  it  causes  mercurial  dermatitis,  which 
is  painful  and  lasts  for  4  to  10  days,  when  the  ointment  has  been 
left  on  the  skin  for  12  to  24  hours  without  being  washed  off;  an 
application  for  2  hours  is  sufficient.  Alcoholic  solutions  of  sub- 
limate require  a  strength  of  i  per  cent  to  be  successful,  and  are 
liable  to  the  same  risk ;  also  they  are  uncertain  in  effect  and  do  not 
destroy  the  eggs. 

A  method  which  I  have  used  several  times  is  to  have  the  hairs 
bearing  the  eggs  removed  by  a  professional  epilator,  and  to  remove 
the  parasites  by  forceps.  This  method  may  be  employed  in  people 
with  very  sensitive  skins  who  have  noticed  the  affection  from  the 


THE    HYPOGASTRIC    REGION.  459 

first.     This  is  frequent,  for  pediculosis  occurs  in  all  classes,  even 
the  most  aristocratic  and  respectable, 

A  method  which  I  have  already  mentioned  is  the  application  of 
Xylol  or  ether  of  petroleum.  This  causes  much  smarting,  but  is 
rarely  followed  by  traumatic  dermatitis.  This  kills  the  parasites, 
but  does  not  destroy  all  the  eggs  with  certainty,  and  for  several 
days  their  possible  hatching  must  be  watched  for. 

SCABIES. 

Scabies  has  a  predilection  for  the  hypogastric  and  genital  regions 
and  the  root  of  the  thighs.  These  lesions,  which  are  usually  the 
first  in  date  and  are  considered  by  some  to  be  more  characteristic 
than  those  of  the  hands,  constitute  what  is  called  the  "calecon"  of 
Hehra.  These  are  the  lesions  of  prurigo  and  especially  those  of 
simple  scratching.  It  requires  a  practised  eye  to  discover  true 
burrows  among  them;  but  the  topography  of  the  lesions  is  pre- 
sumptive, and  the  diagnosis  is  completed  by  careful  examination 
of  the  sheath  of  the  penis,  the  glans,  the  wrists  and  the  palm  of 
the  hands  and  interdigital  spaces. 

For  treatment  see  page  537. 

FOLLICULITIS.     SYCOSIS. 

A  pilary  dermatitis  of  the  pubic  region  is  sometimes  seen,  more 
often  in  women.  Like  certain  forms  of  sycosis  of  the  beard,  it 
consists  in  a  red  epidermatitis,  desquamative  or  exudative  in  dififer- 
ent  cases  and  according  to  the  date  and  the  intensity;  this  super- 
ficial dermatitis  is  studded  with  disseminated  folliculitis.  The 
aflfected  follicles  suppurate  very  little,  but  remain  red  and  chron- 
ically inflamed.  It  is  a  troublesome  affection,  of  long  duration  and 
difficult  treatment. 

Sulphur  lotions  are  not  well  tolerated,  and  mild  sulphur  oint- 
ments are  a  little  better ;  but  the  best  applications  are  composite  tar 
ointments,  such  as : — 

Liquid  tar 5  grammes  3i 

Ichthyol    

Resorcine aa     i  gramme  -gr.  12 

Oil   of  birch 

Lanoline 40  grammes  ^i 


46o  THE    HYPOGASTRIC    REGION. 

These  are  combined  with  epilation  of  the  hairs  in  the  centre  of 
the  chief  points  of  folHcuHtis.  The  right  formula  for  each  case  is 
often  found  only  by  experiment.  In  cases  where  the  folliculitis  is 
secondary  and  the  dermatitis  is  very  eczematous  and  exudative, 
applications  of  nitrate  of  silver  (i  in  15  to  i  in  5)   are  useful. 

Acute  or  chronic  follicular  pustulation  may  sometimes  occur  in 
the  pubic  region,  in  persons  who  present  chronic  sycosis  of  the 
beard,  the  nape  of  the  neck  and  the  eyebrows.  These  are  chronic 
cases  in  which  depilation  by  X-rays  seems  to  be  the  only  resource 
(tint  B  of  radiometer  X). 

Apart  from  these  very  rare  cases,  acute  mercurial  pustular  derma- 
titis may  occur  in  this  region,  from  the  application  of  grey  oint- 
ment for  pediculi.  This  should  be  treated  by  antiphlogistic  reme- 
dies, followed  by  oxide  of  zinc  ointment  (i  in  3)  and  finally  by 
epilation,  if  folliculitis  tends  to  become  chronic. 

PITYRIASIS  SIMPLEX. 

The  hypogastrium,  around  the  pubic  region,  is  often  the  seat  of 
election  of  isolated  elementary  lesions  of  clinical  types  which  have 
no  tendency  to  become  generalised  in  these  regions.  For  example 
pityriasis  simplex  (p.  207)  is  sometimes  seen  above  the  external 
third  of  the  fold  of  the  groin. 

These  consist  of  small  circular  spots,  elongated,  pink  and  squa- 
mous at  the  periphery;  the  squames  being  free  at  their  central  bor- 
der, and  adherent  at  the  periphery.  There  may  be  one,  two,  or  three 
spots  on  each  side  of  the  hypogastrium,  or  on  one  side  only.  \Mien 
one  lesion  fades  away  another  appears.  The  squames  are  some- 
what fatty,  and  on  microscopic  examination  show  the  parasite  of 
Malasses  (p.  207),  which  is  characteristic  of  pityriasis  simplex  capi- 
tis, of  which  these  elements  represent  aberrant  lesions. 

They  are  of  no  importance  in  themselves  and  their  only  interest 
depends  on  the  errors  which  they  may  give  rise  to.  They  are  gen- 
erally confounded  with  all  analogous  lesions  under  the  name  of 
seborrhoeids. 

Treatment  consists  in  friction  with  tincture  of  iodine  (20  per 
cent  in  alcohol),  followed  by  an  ointment  of: — 

Calomel      U^  30  centigrammes  ^gr.  5 

Tannin J  J 

Vaseline      30  grammes  5i 


THE    HYPOGASTRIC    REGION.  461 

PITYRIASIS   ROSEA. 

As  a  rule  the  pityriasis  rosea  of  Gibert  presents  nothing  special 
in  this  region ;  but  when  regional  and  limited  to  2  or  3  lesions  these 
are  misunderstood  by  nearly  all  dermatologists  and  named  sebor- 
rhoeids. 

They  have  all  the  objective  characters  of  pityriasis  rosea;  circular 
spots  of  a  pale  violet  colour,  with  an  iridescent  surface  bordered 
with  a  fringe  of  squames.  Histological  examination  shows  the 
identity  of  these  lesions  with  those  of  generalised  pityriasis  rosea. 

The  duration  of  the  affection  is  that  of  ordinary  pityriasis  rosea. 
The  spots  remain  for  about  2  months  and  slowly  fade  away.  Treat- 
ment is  useless.  The  lesions  are  irritable  and  may  become  ecze- 
matous,  so  that  active  applications  are  contra-indicated;  oxide  of 
zinc  paste  is  the  only  useful  application.  These  lesions  have  no 
great  dermatological  importance,  but  they  may  be  mistaken  for 
syphilides  and  treated  as  such;  an  error  which  is  prejudicial  to  the 
patient. 

PSORIASIS. 

I  have  described,  on  the  sheath  of  the  penis,  a  localised  super- 
ficial psoriasis,  with  a  pink  base  and  fatty  squames,  consisting  of 
large  oval  elements,  discrete  and  few  in  number,  which  may  occur 
on  the  scalp,  in  the  groin  and  on  the  penis.  Very  often  it  is  found 
on  the  hypogastric  region,  outside  the  pubic  hairs,  or  among  them. 
This  is  usually  a  benign  form  of  psoriasis,  of  the  steatoid  type  and 
frequently  superseborrhoeic.  Recurrences  are  few  and  treatment 
is  easy,  but  rebellious  cases  occasionally  occur.  (For  treatment  see 
page  428.) 

VITILIGO.      MORPHOEA. 

The  regions  of  the  h}pogastrium  and  scrotum  are  affected  more 
frequently  than  many  other  regions  by  dyschromias  and  scleroder- 
mias,  of  the  types  known  as  vitiligo  (p.  613)  and  morphoea  (p.  616). 

Sometimes  the  affection  is  exclusively  pigmentary,  arising  in 
the  scrotal  raphe  and  forming  large,  irregular,  white  surfaces  on 
the  inguino-pubic  region.     This  type  is  allied  to  scrotal  vitiligo. 

Sometimes  these  are  true  sclerodermic  patches,  thickened  and 
indurated  in  the  skin,  but  not  projecting  from  the  surface ;  of  a 


462      ■  THE    HYPOGASTRIC    REGION. 

white  colour,  sometimes  surrounded  by  the  hlac  ring,  which  is 
common  in  morphoea.  They  occur  as  one  or  two  oval  spots,  gen- 
erally oblique,  in  the  direction  of  the  groin  and  one  or  two  fingers' 
breadth  above  the  inguinal  fold. 

The  treatment  of  vitiligo  is  nil.  That  of  morphoea  comprises 
electrolysis,  unipolar  or  bipolar,  which  gives  appreciable  results. 
In  a  case  where  the  sclerodermic  patches  were  thin,  numerous  and 
irregular  I  have  seen  high  frequency  give  distinct  results  which  have 
persisted  for  several  years. 

ALOPECIA  AREATA. 

Alopecia  areata  limited  to  the  pubic  region  is  a  dermatological 
curiosity.  Pubic  alopecia  is  generally  observed  in  a  diffuse  form, 
in  the  course  of  general  alopecia  decalvans.  In  vitiligo  of  this 
region  the  hair  On  the  affected  spots  may  become  white  and  fall 
more  or  less  completely.      (For  treatment  see  page  219.) 

INTERTRIGO  OF  THE  HORIZONTAL  FOLD  OF  THE 
HYPOGASTRIUM. 

When  intertrigo  affects  one  of  the  folds  of  the  hypogastrium 
the  two  others  are  generally  affected  also.  Intertrigo  is  seldom 
limited  to  one  of  the  inguinal  folds.  I  have,  however,  seen  inter- 
trigo of  the  horizontal  fold  without  inguinal  intertrigo.  In  these 
cases  there  are  no  peculiar  symptoms  or  flora ;  the  affection  is  strep- 
tococcic here  as  elsewhere.  It  may  assume  a  benign  form  (vide 
inguinal  intertrigo,  p.  264),  or  a  severe  form  (p.  268). 

The  treatment  consists  in  separating  the  opposed  surfaces,  so  as 
to  aerate  them,  by  means  of  a  belt.  When  this  is  impossible  they 
may  be  kept  apart  by  dressings. 

Local  hygiene  requires  soaping  with  tar  soap  and  a  badger  hair 
brush,  when  the  inflammation  is  not  severe.  In  the  latter  case  sweet 
oil  of  almonds  may  be  used.  (For  other  treatment  see  intertrigo 
of  the  groin,  pp.  264  &  269.) 


Seborrhoea 


THE  SCAPULO-THORACIC  REGION 

The  scapulo-thoracic  region  presetits  for  exami-^ 
nation  true  seborrhoea:  characterised  exclusively  by 
the    sebaceous    flux,    for   which    this    region    is    a 
seat    of    election 

Juvenile  polymorphous  acne,  which  is  always 
super-seborrhceic,  is  often  seen  at  its  maximum 
development  and  often  requires  serious  treatment 

Trichophytosis  of  the  scapula-humeral  and  scap- 
ulo-thoracic regions  is  one  of  the  most  common, 
of    the    unexposed    cutaneous    regions 

Favus  of  the  body,  secondary  to  favtis  of  the 
scalp,  is  also  seen  in  this  region  more  often  than 
in  others  


p.  464 


-Acne  polymorphe  .  p.  464 


-  Trichophytosis     .  p.  465 


.  Favus p.  466 


Secondary  syphilis  often  causes  on  the  back  an 
icneiform  eruption,  but  one  formed  of  much  small- 
"r  and  more  generalised  elements,  generally  scat- 
tered all   over   the   back 

Syphilis  often  causes,  on  the  nape  and  scapulo- 
thoracic  region,  localised  semi-ulcerative  eruptions 
of  secundo-tertiary  syphilides 


Acneiform 
ilides   . 


syph- 


p.467 


Tertiary        s  y  p  h- 
ilides p.  468 


The  upper  thoracic  region  is  also  the  region,  pari  ^    ,. 

.       *       .                        &      J  I      [  Pudic    erythema    .  p.  469 
excellence,  of  transient  pudic  erythema -> 

.    .    .  and  one  of  the  regions  where  the  series^  _         ,  , 

r  Roseolas p.  409 

of  roseolas  is  best  observed J 

The  posterior  scapulo-thoracic  region  is  the  scat 
of  scratch  marks  in  verminous  affections,  {vaga- 
bonds disease)  

It  is  also  the  region,  par  excellence,  of  the  small' 
miliary  tumours,  called  eruptive  hydradenomas 

It  is  often  the  seat  of  ncevi  of  different  forms  .    .   Nsevi p.  470 

.    .    .  and  molluscum  pendulum  which  develops  IVIolluscum   pendu- 
in  the  senile  skin him p.  470 

/  shall  conclude  with  the  flat,  grey,  seborrhacic 
or  senile  wart,  which  develops  in  the  posterior  and 
anterior  regions  of   the   thorax 


-  Phtiriasic    prurigo  p.  469 


Hydradenoma  ...  p.  470 


.  Senile  wart  .  . 


p.  471 


464  THE    SCAPULO-THORACIC    REGION. 

SEBORRHOEA. 

Seborrhoea  (defined  exclusively  by  the  seborrhoeic  flux  and  not  by 
the  squame),  presents  an  election  for  the  scapulo-thoracic  and  mid- 
thoracic  regions,  which  is  a  matter  of  daily  observation. 

In  its  pure  state  seborrhoea,  which  never  attains  in  this  region  the 
intensity  it  may  show  on  the  face  (p.  13),  is  characerised  by  two 
symptoms:  (i)  the  skin  is  smooth  and  almost  shiny;  (2)  all  the 
sebaceous  pores  are  marked  by  a  pale  brown  spot. 

In  this  stage  soaping  with  sulphur  soaps  and  daily  friction  with 
fat  dissolving  lotions  is  generally  sufficient: — 

(i)   Resorcine  in  Hoffmann's  liquor:    i   per  cent. 

(2)  Ammonia  in  equal  parts  of  acetone  and  alcohol  (p6  per  cent)  :  i  per 
cent. 

If  these  are  not  sufficient  salicylic  acid  in  oxide  or  zinc  cream 
( I  per  cent  to  7  per  cent)  may  be  used  at  night,  and  washed  off  in 
the  morning.  These  drugs  act  by  exfoliation,  and  sulphur  creams 
may  be  used  with  the  same  object;  or  to  treat  the  seborrhoea  as 
acne  (p.  465). 

ACNE. 

Seborrhoea  rarely  remains  in  its  pure  condition  in  this  region  and 
acne  is  nearly  always  super-posed.  In  severe  cases  the  acne  occu- 
pies the  whole  trunk,  but  it  has  a  predilection  for  the  scapulo-tho- 
racic region. 

It  is  characterised  as  on  the  face  by  the  comedo,  forming  acne 
punctata,  which  becoming  more  or  less  inflamed  constitutes  acne 
suppurata  and  acne  indnrata.  The  latter  may  become  cystic.  In 
some  cases  the  acne  gives  rise  to  numerous  sebaceous  cysts.  One 
or  other  form  predominates  in  diflFerent  cases,  but  they  all  co-exist, 
forming  acne  polymorphe.  I  have  several  times  pointed  out  the 
etiological  conditions  of  acne ;  youth,  sexual  development,  and 
gastric  disorders;  but  the  cause  which  renders  acne  severe  or  gen- 
eralised is  unknown.  But  subjects  who  are  affected  with  acne  often 
suffer  from  hypersteatidrosis  with  a  peculiar  rancid  odour.  The 
condition  is  no  doubt  of  a  chemical  nature. 

The  treatment  of  acne  has  already  been  studied  several  times. 
In  this  region  strong  measures  may  be  carrried  out  without  incon- 


THE    SCAPULO-THORACIC    REGION.  465 

venience,  and  the  exfoliating  method  is  the  most  rapid  and  the 


Fig.  190.     Acne-comedo.      (Fournier's  patient.     St.  Louis  Hosp.   Museum,   No.   1536.) 

best.     In  the   following   formula  the  doses  of  the  drugs  may  be 

infinitely  varied: — 

Precipitated  sulphur 3  grammes     gr.  48 

Resorcine 2  grammes     gr.  32 

Salicylic  acid i  gramme       gr.  16 

Vaseline 30  to  60  grammes     $i  to  ^ii 

This  ointment  is  applied  at  night  and  washed  off  in  the  morn- 
ing. The  doses  may  be  doubled,  or  the  application  may  be  preceded 
by  soaping  with  soft  soap.  If  the  skin  is  sensitive  it  may  be  treated 
by  sulphur  lotion,  sulphur  baths  and  sulphur  soap  (p.  15). 

Up  to  the  present  sulphur  is  the  topical  application  for  acne. 
Radiotherapy  in  weak  doses  (half  tint  B)  has  given  encouraging 
results,  but  further  experience  is  required. 

TRICHOPHYTOSIS. 

The  trichophytons,  especially  when  of  animal  origin,  are  often 
inoculated  outside  the  hairy  regions,  in  some  part  of  the  smooth 


466  THE    SCAPULO-THORACIC    REGION. 

skin;  the  wrist,  nape  of  the  neck  and  the  hands  and  feet.  These 
ringworms  are  more  common  in  the  uncovered  regions,  but  they 
often  occupy  the  scapulo-humeral  region,  the  germs  doubtless  enter- 
ing by  the  collar  of  the  coat  (Fig.  67).  The  form  of  the  trichophy- 
tic  circles  depends  on  the  species  of  parasite  and  the  animal  from 
which  it  originates.  The  common  characters  of  all  these  lesions  are 
their  circular  nature,  their  relatively  large  dimensions,  their  small 
total  number,  their  single  or  bi-regional  localisation,  and  the  identity 
of  all  the  patches  on  the  same  individual. 

The  most  simple  treatment  consists  in  repeated  painting  with 
weak  solutions  of  iodine  in  60  per  cent  alcohol.  It  may  be  men- 
tioned here  that  the  pure  tincture  of  iodine  is  little  used  in  derma- 
tology and  that  the  diluted  tincture  is  a  thousand  times  better: — 

Fresh  tincture  of  iodine 10  grammes     3ii 

Alcohol :      60  per  cent 40  grammes     5i 


FAVUS. 

Favus,  which  is  most  often  situated  on  the  scalp  (p.  199),  may 
occupy  the  whole  body,  including  the  nails  (p.  389).  It  has,  how- 
ever, a  predilection  for  the  scapulo-humeral  region  and  the  arms, 
doubtless  because  the  "cups"  fall  from  the  scalp  into  the  collar  of  the 
coat  and  inoculate  these  regions  more  readily  than  others. 

Favus  of  the  body  is  always  characterised  by  the  sulphur  yellow 
cups,  of  various  sizes  and  chalky  consistence  inserted  in  the  skin. 
Nevertheless  there  are  two  forms  of  cutaneous  favus.  The  one, 
herpetiform  favus,  is  constituted  by  circles  with  red  borders  and 
covered  with  more  or  less  numerous  small  cups.  The  other,  "rocky" 
favus,  is  formed  of  numerous  large  cups,  creating  by  their  juxtapo- 
sition large  placards  of  crusted  appearance  (Fig.  191).  These 
placards  may  increase,  but  never  retrogress  without  treatment.  They 
may  persist  for  life  and  are  only  seen  in  feeble  individuals  who  object 
to  any  kind  of  treatment. 

The  treatment  consists  in  moist  dressings  to  soften  the  cups, 
which  are  then  removed  from  the  skin.  The  parts  are  then  painted 
with  tincture  of  iodine  diluted  with  alcohol  (i  in  5).  These  appli- 
cations must  be  repeated  often  to  avoid  recurrences,  which  are  so 
common  in  hairy  subjects  that  epilation  of  the  whole  of  the  hairs 
of  the  region  may  be  advisable. 


THE   SCAPULO-THORACIC    REGION. 


467 


ACNEIFORM  SYPHILIDE. 


The  acneiform  syphilide  is  one  of  the  later  forms  of  secondary,., 
syphiHs  which  occur  at  the  end  of  the  first  year  of  the  disease  .  ,;, 

It   resembles  a  red 
acne,     but     the     ele^ 
ments  are  much  more.: 
n  u  m  e  r  o  u  s  ,    more' : 
equally    distribut  e  d  ,  > 
and     less     polymor-. 
phous    than    in    true 
acne.    These  elements 
may  cover  the  whole 
of  the  back  with  fine 
brownish  maculae, 
many    of    them    mili- 
ary, but  all  with  a  fol- 
licle    in     the     centre. 
The  brown  colour  of 
these  elements  differs 
from   the   red   colour 
of    those    of    recent 
acne.      Lastly,     there 
are  no  polymorphous, 
indurated,     cystic    or 
suppurative  elements ; 
all     the     lesions     are 
monomorphous. 

Analogous  lesions 
are  found  on  the  an- 
terior surface  of  the 
trunk,  in  regions 
which  are  never  af- 
fected by  acne,  such 
as  the  flanks  and  the  umbilicus.  The  diagnosis  is  confirmed  by  the 
presence  of  adenitis,  mucous  patches,  etc.,  and  by  the  history  of 
recent  syphilitic  infection. 


Fig:.  191.     Favus    of    the    body    and    arm. 
(Sabouraud's   patient.        Photo    by    Noir6.) 


468  THE    SCAPULO-THORACIC    REGION. 

SECUNDO-TERTIARY    ULCERATIVE  SYPHILIDE. 

Secondary  syphilis  having  been  passed  and  badly  treated,  some 
years  later  a  tertiary  serpiginous  syphilide  may  appear,  formed  of 
superficial  miliary  cutaneous  gummata,  or  of  larger  and  more  dis- 


s.     *■. 


'Fig,  192.     Tertiary    ulcerative    syphilides    in    the    form    of    bouquet. 
(Jeanselme's   patient.     Photo    by    NoirS. ) 

tinct  ulcerative  lesions,  agminated,  but  in  groups  and  not  in  circles. 
An  example  of  this  is  shown  in  Fig,  192,  in  a  region  where  ter- 
tiarv  lesions  are  not  uncommon. 


TttE   ScAPULO-TMORACIC   r£G16N.  4^ 

This  should  be  borne  in  mind  when  lesions  of  this  kind  are  seen, 
with  a  serpiginous  or  ulcerative  tendency  and  limited  to  a  small 
area. 

The  therapeutic  test  will  confirm  the  diagnosis;  but  these  lesions 
always  require  active  treatment. 

PUDIC  ERYTHEMA. 

Some  women,  when  they  undress,  under  the  influence  of  emotion 
or  embarrassment,  or  even  without  perceptible  emotion,  present 
on  the  chest  large  disseminated  erythematous  patches,  which  may 
be  mistaken  for  a  permanent  lesion.  This  transient  erythema  indi- 
cates hyper-excitability  of  the  vaso-motor  nerves,  which  is  often  on 
a  par  with  urticarial  reactions,  dermographism,  etc. 

ROSEOLAS. 

Roseolas  of  all  kinds  are  first  seen  on  the  chest  (p.  578).  But  as 
they  are  all  (except  pudic  roseola)  observed  on  the  whole  trunk, 
they  will  be  studied  with  the  general  dermatoses.  However,  sev- 
eral roseolas,  especially  the  syphilitic,  are  more  marked  in  the  scapu- 
lo-thoracic  region  and  the  flanks.  This  region  should  always  be 
examined  when  secondary  syphilis  is  suspected. 

PHTHIRIASIS. 

The  lesions  of  phthiriasis  of  the  body  (Pediciilus  vestimentoruniQ 
are  always  most  marked  on  the  back  between  the  shoulders.  They 
are  erosive  and  pigmentary ;  two  characters  which  are  never  absent. 
The  pigmentation,  diffuse  or  in  patches  occupying  the  situation  of 
recent  lesions,  is  brown  or  grey  and  more  phenomenal  in  old  stand- 
ing cases.  The  erosive  lesions  are  made  by  the  nails,  and  as  the 
right  hand  can  only  scratch  the  left  shoulder,  and  vice  versa,  the  par- 
allel linear  erosions  are  always  transverse  and  ascending  towards  the 
shoulder.  The  patient  often  denies  his  phthiriasis,  and  it  is  not  he 
who  must  be  examined,  but  the  seams  of  his  clothes. 

Treatment  consists  in  disinfection  of  the  clothes,  for  the  white 
louse  does  not  remain  on  the  body,  and  except  in  very  hairy  persons. 


4^0  THE   SCAPULO-THORACIC    REGION. 

does  not  lay  its  eggs  on  the  hairs  of  the  body,  but  on  those  of  the 
clothes.  The  mercurial  fumigations  which  are  often  advised  are 
therefore  useless.  Zinc  paste  with  menthol  may  be  applied  on  the 
body  to  ease  the  pruritus,  but  this  ceases  as  soon  as  the  clothes 
are  purified. 

ERUPTIVE  HYDRADENOMA. 

The  name  eruptive  hydradenoma  is  applied  to  minute  benign 
tumours,  the  size  of  lichen  papules,  forming  slight,  reddish  brown 
projections  on  the  skin,  where  they  may  occur  in  hundreds  (p.  630). 
They  are  sudoriparous  cysts,  possibly  congenital,  and  nsevoid,  which 
attain  a  size  of  about  3  millimetres  after  having  remained  hitherto 
invisible.  Each  forms  a  small  induration  in  the  skin.  Their  place 
of  election  is  the  throat  and  they  are  more  common  in  women.  They 
never  give  rise  to  malignant  tumours. 

They  require  no  treatment  except  for  aesthetic  purposes,  when 
they  may  be  treated  either  by  electrolysis  as  for  naevi  (p.  5)  or 
by  fine  galvano-puncture,  to  reduce  each  tumour  without  scarring. 


NAEVI. 

True  naevi,  angiomata  and  lymphangiomata  (p.  626)  may  develop 
in  the  scapulo-thoracic  region.  The  physician  is  most  often  con- 
sulted for  naevi  in  this  situation  on  account  of  the  custom  of  wear- 
ing low  dresses  in  women.  The  treatment  of  these  lesions  does  not 
dififer  in  this  -situation  from  that  of  other  regions. 


MOLLUSCUM    PENDULUM. 

In  women  about  the  age  of  40,  with  a  skin  which  becomes  wrin- 
kled, thin  and  senile,  minute  pedunculated  tumours  sometimes 
develop,  the  size  of  a  millet  seed.  These  constitute  molluscum  pen- 
dulum (p,  627).  They  may  easily  be  got  rid  of  by  the  fine  galvano- 
cautery.  This  is  instantaneous,  almost  painless  and  gives  perfect 
results.  Sometimes  from  10  to  20  of  these  tumours  may  be  seen  in 
different  degrees  of  development. 


THE    SCAPULO-THORACIC    REGION.  471 

FLAT  SEBORRHOEIC  WART. 

The  flat  seborrhoeic  wart  is  wide  and  flat  as  its  name  indicates, 
and  is  scarcely  raised  above  the  skin.  Its  surface  is  papillomatous 
and  its  colour  dirty  grey.  It  is  one  of  the  lesions  often  seen  in 
senile,  or  prematurely  senile,  skins  (p.  622).  One  or  two  of  these 
may  remain  for  years ;  and  then,  generally  after  40,  they  multiply 
and  may  be  seen  in  hundreds.  The  largest  are  one  centimetre  in 
length,  and  half  a  centimetre  in  width,  and  project  for  2  millimetres. 
They  are  always  villous,  grey  or  brown.  The  skin  thus  has  a  dirty 
appearance,  covered  with  unsightly  "senile  scum."  The  warts 
should  be  destroyed  by  concentrated  chromic  acid  by  the  physician ; 
and  chromic  acid,  i  in  5  to  i  in  10.  may  be  used  by  the  patient. 
Sulpho-carbolic  acid  may  also  be  used.  General  friction  of  the 
body  with  tincture  of  thuja  (i  in  5)  is  only  of  mediocre  value,  and 
has  rather  a  moral  efl^ect.  The  lesions  may  be  destroyed  by  the 
galvano-cautery,  but  great  care  is  required  to  avoid  scarring. 


ANTERIOR  AND  POSTERIOR  MEDIO-THORACIC 
REGIONS 


The  anterior  medio-thoracic  region  only  presents  a  few  affections 
which  are  pecuHar  to  it,  but  several  which  occur  in  this  situation 
assume  special  characters. 


It  is  first  one  of  the  regions  par  excellence  for\ 
seborrhcea;  hypersteatosis  of  the  skin J 

.  .  .  and  on  the  seborrhoeic  soil  pityriasis  sim- 
plex, steatoid,  diffuse  or  more  often  figured,  is  a 
common  affection 

The  medio-thoracic  region  is,  with  the  costal 
regions,  the  one  xvhere  pityriasis  versicolor  is  most 
often    found 

Normal  psoriasis  is  rare  but  the  form  of  psoriasis 
with  fatty  squamcs,  so  often  super-seborrhaic,  is 
often   found  in   this  region 


Seborrhoea 


p.  472 


Super-sebor- 

rhoeic     pityriasis  p.  473 


Pityriasis 
color  . 


P-474 


Lastly,  ordinary  acne  is  not  limited  to  this  re- 
gion, but  acne  necrotica  or  varioliforme  often  oc- 
curs exclusively 


Psoriasis 


-Acne  necrotica 


p.  476 


P-J77 


SEBORRHOEA. 

Seborrhoea,  or  the  non-squamous  flux  of  sebum,  which  we  have 
studied  on  the  face,  presents  its  maximum  in  several  parts  of  the 
axial  line  of  the  body,  one  of  which  is  the  medio-thoracic  region. 
Youth  is  the  age  of  seborrhoea,  but  it  is  found  in  the  adult  between 
30  and  40,  or  later.  In  these  places  there  is  hyper-secretion  of  both 
sebum  and  sweat;  hyperstcathidrosis  {Bcsnicr).  The  characteristic 
element  of  seborrhoea,  the  cocoon,  is  found  here,  but  it  is  less 
easily  expressed  from  the  skin.  The  micro-bacillus  is  found  on 
examination. 

Seborrhoea  in  this  region  is  characterised  chiefly  by  its  com- 
plications;  acne  (p.  15),  acne  necrotica  (p.  235),  and  super-sebor- 
rhoeic  pityriasis  (p.  208).  It  rarely  requires  treatment  by  itself 
(chloric  acne,  p.  236),  but  treatment  becomes  necessary  to  avoid 
complications. 


MEDIO-THORACIC    REGION.  4^3 

Sulphur  soap  and  lotion  should  be  used  frequently,  and  daily 
friction  with  the  following: — 

Hoflfmanri  s    liquor 250  grammes     ^i 

Spirit  of  lavender 1  ^^  ^^  grammes  Isi 

Saponmed   coaltar J  J 

Tincture  of  iodine v  drops  m.x 

This  is  generally  sufficient  to  keep  the  skin  in  good  condition. 
The  absolute  cure  of  seborrhoea,  in  any  part  of  the  body,  is  so  far 
impossible. 


SUPER-SEBORRHOEIC  PITYRIASIS. 

This  disease  is  called  by  different  authors,  parasitic  eczema 
(Besnier)  ;  pityriasis  circinata  et  marginata  (Vidal)  ;  eczema  mar- 
ginatum (Hebra)  ;  seborrhoea  corporis  (Duhring)  ;  and  medio- 
thoracic  dermatitis  (Brocq).  It  is  constituted  by  pink  spots  scat- 
tered irregularly  on  the  medio-thorax,  chest  or  back,  which  may 
assume  different  forms,  the  chief  characteristic  of  which  is  their 
medio-thoracic  localisation. 

They  commence  by  a  pink  circumpilary  point  which  enlarges  and 
becomes  a  spot  with  a  pink  centre  and  squamous  border.  Some- 
times several  spots  coalesce,  forming  a  polycyclic  lesion.  This  dis- 
ease, when  untreated,  lasts  for  years ;  when  treated  it  quickly  dis- 
appears, but  recurs.  It  is  a  simple  pityriasis  allied  to  pityriasis  sim- 
plex of  the  scalp,  for  it  has  the  same  mycotic  parasite,  the  spore  of 
Malasses  (bottle  bacillus  of  Unna,  p.  207).  The  squames  are  gen- 
erally fatty,  or  appear  so  for  the  same  reason  that  causes  steatoid 
pityriasis  of  the  scalp  (p.  208). 

Treatment  is  simple  and  consists  in  daily  friction  with  tincture  of 
iodine  in  Eau  de  Cologne  (10  per  cent),  or  sulphur  ointment  and 
soap.  Nothing  is  easier  than  to  cause  the  disappearance  of  this 
lesion,  but  it  recurs,  especially  when  treatment  has  not  been  long 
continued.  Medio-thoracic  circinate  and  marginate  pityriasis  is 
generally  super-seborrhoeic  (p.  472)  and  is  kept  up  by  hypersecre- 
tion of  sweat.  These  conditions  impose  scrupulous  hygiene  of  the 
skin  in  order  to  avoid  the  series  of  super-seborrhoeic  affections. 


474 


MEDIO-THORACIC    REGION. 


Fig.  193. 


Steatold,  figured,  super-seborrhoeic  pityriasis  of  the  jucdio-tlioiacic  re-ion, 
(Sabouraud's  patient.     Photo,   by  Noirfe.) 


PITYRIASIS  VERSICOLOR. 


Pityriasis  versicolor  is  characterised  by  large,  apparently  hyper- 
chromic  patches,  cafe  au  lait  coloured,  disseminated  or  fused 
together  in  placards,  and  covering  a  varied  extent  of  the  body.  The 
usual  region  affected  is  the  medio-thorax,  where  geographical 
patches  occur  on  the  anterior  and  dorsal  thoracic  region;  some- 
times on  the  abdomen  and  root  of  the  limbs  (Fig.  194). 

These  patches  are  not  raised  and  present  a  characteristic  sign; 
when  scratched  with  the  nail  a  thin  wrinkled  squame  is  easily 
detached,  which  shows  the  parasite,  when  examined  microscopically. 
This  is  a  superficial  epidermic  mycosis,  favoured  by  hvpersteatidro- 


MEDIO-THORACIC    REGION. 


475 


sis,  and  caused  by  the  microsporum  furfur  (named  by  Robin,  but 
discovered  by  Eichstedt). 

The  squame  is  prepared  in  a  drop  of  liquor  potassse    (40  per 
cent)  between  two  glass  slides.    In  extempore  preparations  it  may 


Flgr.  194.     Pityriasis  versicolor.     (Jacquet's  patient.     Photo  by  Dubray.) 


be  warmed.  When  examined,  without  staining,  with  a  power  of 
300  diameters,  it  shows  a  meshwork  of  mycelial  filaments,  between 
which  are  nests  of  spores.    These  spores  are  of  various  sizes,  single 


476  MEDIO-THORACIC    REGION. 

or  double,  present  a  double  outline,  and  are  always  observed  in 
groups. 

Pityriasis  versicolor  is  common  in  tuberculous  subjects  for  some 
unknown  reason,  and  is  often  consanguineous.  It  is  kept  up  by 
the  wearing  of  flannel,  and  by  sweating.  It  may  apparently  dis- 
appear to  appear  again.  It  is  always  chronic  and  lasts  for  years, 
extending  slowly,  and  in  rare  cases  may  become  generalised  over 
nearly  the  whole  body  (Fig.  194).  In  such  cases  the  treatment 
is  difficult,  and  chrysophanic  ointments  are  required  (i  per  cent). 
In  ordinary  cases  friction  with  weak  iodine  solutions  in  alcohol  are 
to  be  preferred,  repeated  daily  for  several  weeks. 

Tincture  of  iodine 10  parts 

Alcohol :  60  per  cent 70  parts 

Spirit  of  lavender 20  parts 

The  disease  is  apt  to  recur  and  the  linen  should  be  disinfected. 


STEATOID    AND    SUPER-SEBORRHOEIC    PSORIASIS. 

Common  psoriasis  has  no  predilection  for  the  medio-thorax  but 
psoriasis  with  fatty  squames,  or  super-seborrhoeic  psoriasis,  has.  It 
is  this  which  is  called  by  some  authors  psoriasiform  seborrhoeid,  or 
nummular  seborrhoeic  eczema,  etc.  It  presents,  on  the  chest,  its 
essential  clinical  characters;  the  thick,  chalky,  adherent,  foliaceous 
squame,  raised  above  the  skin.  The  subjacent  skin  is  red,  and  when 
the  squame  is  removed,  shows  blood  points.  This  form  of  psoriasis 
shows  nearly  the  same  characters  as  the  prethoracic  pityriasis  which 
we  have  just  studied.  It  is  chronic,  slowly  progressive  and  does 
not  retrogress.  Apart  from  its  special  characters,  the  other  locali- 
sations differentiate  it  from  pityriasis,  and  also  its  histological 
structure. 

It  is  very  resistant  to  external  treatment  and  strong  oil  of  cade 
ointments  are  required: — 

Resorcine 1  1  _ 

T,         ,,        .         ,  ^  aa     I  gramme   V  aa  gr.  48 

Turpeth  mineral J  J 

Pyrogallic  acid 75  centigrammes  gr.  36 

Oil  of  cade 1  1 

Lanoline L  aa  10  grammes  I  aa  Ji 

Vaseline 


MEDIO-THORACIC    REGION. 


477 


Chrysarobin  in  ointment  (i  in  40)  or  in  solution  in  chloroform 
and  covered  with  traumaticin,  may  also  be  used. 


Fig.  195.     Super-seborrhoeic   psoriasis. 
(Sabouraud's    patient.     Photo,    by    NoirS.) 


ACNE.    ACNE  NECROTICA. 


Acne  is  not  usually  localised  to  the  medio-thoracic  region,  but 
extends  uniformly  on  the  whole  of  the  chest  and  back  (p.  464). 

Necrotic  acne,  on  the  contrary,  has  a  tendency  to  limit  itself  to 
an  ellipitical  region  about  8  inches  long,  by  4  wide,  exactly  in  the 
centre  of  the  medio-thoracic  region.  However,  necrotic  acne  seldom 
takes  this  localisation  except  in  severe  cases,  when  it  has  invaded 
the  whole  scalp,  or  the  face.  In  this  case  it  also  invades  the  ver- 
tebral groove  in  the  medio-thoracic  region.  It  occurs  more  often 
in  males  than  females  and  is  as  common  at  40  years  of  age  as  at 


478 


MEDIO-THORACIC    REGION. 


1 8  or  20.    There  is  no  particular  cause  known  to  explain  the  etiology 
of  acne  necrotica. 

The  elements  consist  of  flat,  wide,  umbilicated,  peripilary  pus- 
tules. These  grow  quickly  and  dry  up  without  opening  and  are 
transformed  into  minute  scabs,  set  in  the  skin.    These  scabs  remain 


S3i^^R??5^ 


Figr.  196.     Presternal  Acne   Necrotica. 

(Besnier's    patient.     St.    Louis    Hosp.    Museum,    No.    498.) 

(cr,    crust    in   situ:    ci,    varioliform   cicatrix.) 

for  some  time  and  leave  a  varioliform  cicatrix  after  they  have 
fallen. 

The  disease  proceeds  by  intermittent  crops,  which  may  be  cured 
by  many  applications ;  but  nothing  cures  with  certainty  the  disease 
itself,  nor  prevents  recurrence. 

The  best  local  applications  are  sulphur  and  mercury  ointments : — 

Precipitated  sulphur 3  grammes  gr.  48 

Cinnabar i  gramme  gr.  16 

Oxide  of  zinc S  grammes  gr.  80 

Vaseline 30         "  5i 


MEDIO-THORACIC    REGION.  479 

These  are  applied  at  night  and  washed  off  in  the  morning.  Daily 
alcoholic  friction  and  weekly  sulphur  baths  are  also  useful  in  pre- 
venting recurrence.  But  this  affection,  which  is  so  benign  in 
most  cases,  sometimes  become  formidable  by  the  constant  repeti- 
tion of  its  outbreaks  and  the  disfiguring  scars  which  they  leave. 


THE  VERTEBRAL  GROOVE. 


The  vertebral  groove,  like  all  the  axial  regions 
of  the  body,  is  particularly  predisposed  to  sebor- 
rhoea,  which  presents  itself,  not  in  the  Huent  form, 
but  as  brown  spots  at  the  sebaceous  orifices  .    .    . 


Seborrhoea  ....  p.  480 


Many  affections  develop  better  on  a  seborrhocic^  ATpfijo  thorar' 
^in;  such  as  pityriasis  simplex  of  the 
also  called  circinate  and   niarginate 


skin:  such  as  pityriasis  simplex  of  the  medio-thorax,  Y       u     ■     ■ 

■^  '  '  '  \      pityriasis p. 


This   is   also    the   case   with   a   certain   form   oH  Super-seborrhoeic 
psoriasis   which  we   have  already  studied  ....  J      psoriasis p.  480 

And  zvith  pityriasis  versicolor,   but   this  is  less'y  td.-x  ^-  ^• 
.,,..,,  .      ,       .      .     .  ,  I  Pityriasis     v  e  r  s  1- 

strictly  limited  than  simple  pityriasis  to  the  verte-  r         ,  o 

bral  groove J 

/  shall   also   mention    the   flat  seborrheic   wart, 
with    its    grey    and    villous    surface,    ivhich    often 

multiplies    on    fatty    skins    when    they    lose    their '  •  P-  4 

youthful   qualities 


SEBORRHOEA. 

Seborrhoea,  defined  by  the  non-sqnamous  sebaceous  flux,  has  a 
marked  preference  for  the  axial  Hne  of  the  body,  and  super-sebor- 
rhoeic  affections  are  found  in  the  whole  length  of  the  vertebral 
groove. 

The  seborrhoea  itself  is  characterised  less  by  an  evident  fatty 
flux  than  by  fine  brownish  points,  marking  each  sebaceous  orifice ; 
rarely  by  acne,  except  in  the  scapulo-thoracic  region,  where  it  has 
already  been  studied  (p.  464). 

In  this  degree  seborrhoea  only  requires  mention  as  the  necessary 
substratum  for  the  development  of  the  affections  which  we  shall 
proceed  to  study. 

Sulphur  baths  and  soap  or  alcoholic  lotions  with  tar  are  gen- 
erally sufficient  to  prevent  the  morbid  states  which  may  be  super- 
posed. 

Saponified   coaltar        50  grammes    3ii 

Spirit  of  lavender 25  grammes     5i 

Alcohol :  60  per  cent 225  grammes     ^i 


THE    VERTEBRAL    GROOVE. 
SUPER-SEBORRHOEIC  PITYRIASIS. 


The  circinate  and  marginate  pityriasis  of  Vidal,  the  seborrhoea 
corporis  of  Diihring,  or  pityriasis  simplex  super-seborrlioeica,  often 
shew  their  most  typical  elements  between  the  two  shoulder  blades  cai 

both  sides  of  the  verte- 
bral groove.  They  oc- 
cur on  skins  the  pores 
of  which  are  visibly 
seborrhoeic. 

They  consist  of  small 
red  patches  clearly 
defined  by  a  yellow 
crusted  border,  or 
when  this  is  removed, 
by  a  pink  moist  mar- 
gin, resembling  a  nail 
scratch.  This  disease 
is  very  chronic  and  lia- 
ble to  recurrence,  but 
has  a  benign  character. 
The  elements  may  be 
dispersed  by  sulphur, 
mercury,  and  weak 
iodine  or  tar  prepara- 
tions (p.  473),  but  re- 
currence is  the  rule, 
and  is  favoured  by  the 
hypersteatidrosis  of  the 
region    (Bcsnier). 

SUPER-SEBOR- 
RHOEIC PSORIASIS. 

There  is,  as   I  have 

remarked      before,      a 

form        of       psoriasis 

which  has  marked  seborrhoec  affinities.     I  have  described  a  super- 

seborrhoeic  psoriasis  of  the  chest  (p.  476),  and  there  is  a  clinical  type 

which  may  be  strictly  limited  to  the  vertebral  groove.   Tliis  gen- 


Fig.  197.       Psni  •  \  e 

(Sabouraud's    patient.       Photo,    by    Noir6.) 


482  THE  VERTEBRAL  GROOVE. 

erally  takes  the  form  of  psoriasis  guttata  and  occurs  as  a  band  as 
wide  as  the  hand  in  the  middle  of  the  back,  sometimes  expanded  in 
larger  patches  on  the  sacral  region  (Fig.  197).  (For  treatment 
see  page  476.) 

PITYRIASIS  VERSICOLOR. 

Pityriasis  versicolor  usually  occurs  on  the  front  and  back  of  the 
thorax,  and  it  may  invade  the  whole  of  the  back  and  even  the  whole 
body  except  the  extremities  (Fig.  194).  It  is  sometimes  partially 
limited  to  the  vertebral  groove,  but  this  is  rare.  The  diagnosis 
has  to  be  made  from  medio-thoracic  pityriasis  simplex.  The  latter 
consists  of  patches  which  have  crusted  edges;  pityriasis  versicolor 
never  causes  any  appreciable  projection  above  the  skin,  and  its 
cafe-au-lait  colour  distinguishes  it  from  all  other  affections  of  the 
same  situation.  However,  pityriasis  in  the  newly-born  sometimes 
causes  a  florid  erythematous  lesion  which  is  very  different  from 
the  typical  lesion.     This  is  a  detail  to  be  remembered. 

Treatment  consists  in  daily  friction  with  a  2  per  cent  solution  of 
iodine  in  60  per  cent  alcohol. 

FLAT  SENILE  WART. 

The  flat,  grey  or  brown,  seborrhoeic,  contagious,  senile  wart, 
"seborrhoeic  or  senile  scum,"  flattened  on  the  skin,  is  rarely  lo- 
calised to  the  vertebral  groove,  but  occurs  on  the  whole  of  the 
back  and  even  on  the  whole  trunk  and  face.    (Vide  p.  30  and  p.  622) . 


INFERIOR  THORACIC  REGION. 


The  lower  thoracic  region  may  present  all  forms 
of  dermatoses,  but  none  which-  are  peculiar  to  it. 
The  only  one  zvhich  has  a  certain  election  for  this 
region  is  intercostal  zona 

Apart  from  this  eruption,  certain  dermatoses  are 
common  to  this  region  and  to  the  vertebral  groove, 
such  as  pityriasis  versicolor 

.    .    .   and  the  flat  contagious  senile  zvart  ....     Senile  wart   .    .    .  p 

Other  general  dermatoses,  such  as  pityriasis 
rosea  of  Gibert 

.  .  .  and  lichen  planus,  present  their  elements 
disposed  in  oblique  lines,  outwards  and  downwards 
following  the  ribs 


Intercostal    zona  .  p.  483 
-Pityriasis     versi- 
color   p.  482 


Pityriasis  rosea   .  p.  521 
Lichen  planus  .    .  p.  555 


But  these  particular  topographical  distributions  do  not  require 
description  in  this  region,  and  the  general  eruptions  will  be  con- 
sidered later  on. 

ZONA. 


Intercostal  zona  is  a  common  lesion  on  the  trunk.  It  begins 
either  by  an  intense  neuralgia,  or  by  a  burning  sensation,  or  by 
its  eruption  without  any  premonitory  local  symptoms.  As  in  herpes, 
erythema  multiforme,  etc.,  there  may  be  general  symptoms  of 
malaise,  fever  and  sore  throat;  at  other  times  the  zona  follows  a 
traumatism ;  but  sometimes  it  occurs  withotit  anything  which  ex- 
plains or  precedes  it.  It  is  an  eruption  of  the  herpetic  type  (herpes 
zoster),  forming  vesicular  bouquets,  disseminated  along  a  nearly 
horizontal  line,  generally  situated  at  the  middle  of  the  thorax,  and 
never  occupying  more  than  half  the  circumference  of  the  body 
from  the  vertebral  column  to  the  sternum,  or  a  part  only  of  this 
course. 

The  vesicular  bouquets  comprise  from  5  to  20  vesicles,  and  from 
3  to  2.0  similar  bouquets  rnay  occur  along  the  line  indicated,  their 


484 


INFERIOR    THORACIC    REGION. 


major  axis  being  always  in  the  direction  of  this  line. 

The   vesicles  are  of 
the  usual  size  in  her- 
pes    with     the    same 
oval  form  and  the  same 
disposition.     They  are 
situated  on  a  common 
erythematous  base;  be- 
come turbid  on  the  sec- 
ond day  and  dry  up  on 
the   1 2th  or   15th  day, 
when  they  are  not  ac- 
companied by  local  ne- 
crosis.    If  this  occurs, 
when  they  are  open,  or 
rupture    spontaneously 
they  show  a  grey  ulcer- 
ation with  a  bright  red 
border.    This  is  a  spot 
of  local  gangrene  (gan- 
grenous  zona),   which 
takes   longer  to  heal, 
and  leaves  a  cicatrix.     All  the  vesicles  of  zona  may  undergo  this 
process,  or  the  necrosis  may  be  limited  to  one  group  or  to  a  few 
vesicles  of  each  group. 

After  healing,  zona  is  often  followed  by  intense,  persistent  neu- 
ralgic pain,  which  may  last  for  six  months  or  more,  especially  in 
old  people,  or  in  subjects  having  organic  disease,  such  as  diabetes. 
The   prognosis   should   therefore   always   be  guarded. 

The  treatment  of  zona  is  nil.  The  affected  region  may  be  cov- 
ered with  glycerole  of  starch,  or  powder,  and  covered  with  a  wool 
dressing.  This  diminishes  the  intense  pain  in  certain  cases.  In 
persistent  neuralgia  I  have  had  good  results  with  a  spray  of  chloride 
of  methyl.  This  must  not  be  applied  to  the  skin  directly,  but  on 
a  layer  of  oil-silk  or  protective.  This  application  is  generally  fol- 
lowed after  two  hours  by  intense  pain,  lasting  for  3  or  4  hours, 
but  the  neuralgia  is  afterwards  much  diminished  and  may  dis- 
appear completely. 

The  cause  of  zona  is  unknown  and  even  the  cause  of  the  re- 


Flg.  198.     Zona    of    the    thorax. 

(Lalller's    patient.       St.     Louis    Hosp.     Museum, 

No.    210.) 


INFERIOR   THORACIC    REGION.  485 

appearance  of  the  horizontal  groups  of  vesicles,  for  they  do  not 
correspond  to  the  direction  of  the  ribs  or  intercostal  nerves.  This 
has  led  to  the  hypothetical  application  of  the  metameric  theory  to 
its  genesis. 

Certain  cases  of  contagion  of  zona  have  been  reported,  and 
some  authors  believe  in  its  microbial  origin ;  but  by  direct  exam- 
ination and  culture  even  the  suppurating  vesicles  of  zona,  like  those 
of  herpes,  are  normally  aseptic,  with  our  present  methods  of  in- 
vestigation. 


THE  BREAST. 

The  breast  presents  for  examination  a  great  number  of  derma- 
toses, some  of  which  are  special  to  it ;  but  a  much  greater  number 
are  common  to  several  regions  and  assume  peculiar  characters 
and  symptoms  in  this  situation. 


The  nezvly  born  present  at  birth  a  double  mam-^  Mammitis     of    the 
7nitis  which  may  require  supervision  and  treatment j      newly  born  ...  p.  487 

The  pregnant  woman  may  present  before  delivery^ 
^   .    ,   ,  ...  ,  .  ,  u      X  11        J    J,       Mammitis  of  preg- 

o   painful   mammitis,   which    may   be   followed   byy  „ 

,..,,.  nancy p.  487 

divers    infections J  ^ 

Mammitis  in   the   lymphangitic   or   erysipelatous'] 
,  ■      ^j       f  £         i^-^i        I.  ■    \  Mammitis  of  lacta- 

form,    or    in    the    form    of    multiple    abscesses,   is  ^ 

especially  common  in  the  course  of  lactation   ■    •    -J  P-4o7 

Most    of    these     lesions    arise    from     infection^. 

through  a  tre-existing  fissure  of  the  breast  ....  J  ^'  "* 

Syphilitic  chancre  of  the  breast  is  common  and 
should  be  recognised  without  fail,  for  its  origin  may 
give  rise  to  important  problems 

Secondary   syphilis   of   the   breast  is   much    less\ 
peculiar  and  will  only  be  briefly  mentioned  .   .    .J  Y    Vv  P- 49" 

Eruptive  hydradenoma  may  be  mistaken  for  the~\ 
papular    eruption    of    syphilis,    and    requires    <///- 1  Hydradenoma  .     .  p.  49^ 
ferentiation J 


Syphilitic    chancre  p.  489 


Acne  is  not  peculiar  to   the  breast  but  is  com-\ 


,,        ,     ,  I  Acne P-490 

mon   on   the   chest 


Eczema  of  the  breast  is  a  streptococcic  epider-\ 
matitis,  zvhich  has  peculiar  causes  and  characters^ 

.    .    .  also   scabies   tvhich   is   the   most   frequcnt~\  ^    ,  . 

,    .^  r  Scabies p.  492 

cause   of  it J 

There  is  an  intertrigo  of  the  sub-mammary  fold,\^ 

,,     .,         ,        ,   ,  ,,  f  Intertrigo P- 493 

as  m  all  other  closed  folds J  ^  ^ 


P-493 


Intcrtriginous  trichophytosis  is  sometimes  seen  '"l  rp  •  1      1 
le  sub-mammary,  as  in  the  inguinal  fold  ...    .J  ^ 

-Tuberculosis   .    .    .  p.  494 


tlu 

There  is  a   lupus  of  the  breast  zuithout  special' 

characters;    also    a    sub-cutaneous    and    glandular 

form    of    tuberculosis,    which    requires    a    special 

description 

Syphilitic  gumma   of  the   breast,  although   rare,\^ 

r  Gumma P-49-; 

requires  mention ■>  *^     ^ 


THE    BREAST.  487 

The  breast  is  the  almost  unique  situation  of  a~\ 
chronic,   exulcerative   affection,   known   as   Pagef'j  I  Paget's  disease  .  .  p.  494 
disease   of  the  nipple J 

Tumours  of  the  breast  give  rise  to  certain  con-^.  „  ,     ,, 

...  ...  .  ,       .  ■     •        rumours     of     the 

sideratwns  which   may   interest   t.ie   dermatolopist  y     ,         ^ 

,.     /  I      breast P- 495 

who   practises   radiotherapy 


Lastly,  cancers  of  the  skin;  chorio-epithelio-  ■ 
matosis,  cancerous  lymphangitis,  cancer  en  cui- 
rasse,  are  included  among  the  diseases  which  may 
be  treated  and  sometimes  cured  by  dermatological 
radiotherapy 


Chorio  -  epithelio- 
matosis.  Can- 
cerous lymphan- 
gitis   p.  496 


MAMMITIS   OF  THE   NEWLY-BORN. 

Infants  of  both  sexes,  during  the  first  days  after  birth,  nearly 
always  present  some  sign  of  activity  of  the  mammary  glands. 
There  may  be  a  simple  or  dotible  mammitis,  with  excretion  of 
milk,  accompanied  by  inflammatory  phenomena,  including  raised 
temperature  and  enlarged  glands  in  the  axillae. 

This  process  is  usually  benign  and  disappears  in  a  few  days; 
but  occasionally  an  abscess  forms  near  the  nipple,  the  size  of  an 
almond,  which  requires  incision. 

Treatment  is  confined  to  strict  local  cleanliness.  An  aseptic  oint- 
ment of  oxide  of  zinc  (i  to  4)  should  be  applied,  and  over  this 
starch  poultices,  renewed  four  times  a  day;  these  are  antiphlogis- 
tic and  regulate  the  local  temperature. 

MAMMITIS   OF   PREGNANCY. 

In  some  women  there  occurs  a  tendency  to  the  secretion  of 
milk  after  the  fourth  month  of  pregnancy.  This  phenomenon 
seldom  becomes  inconvenient  till  parturition,  and  infection  result- 
ing from  "the  open  door"  is  rare.  Local  asepsis  must  be  main- 
tained by  daily  alcoholic  lotion  and  the  application  of  sterilised 
glycerole  of  starch. 

MAMMITIS   OF  LACTATION. 

This  is  common  and  serious.  It  is  always  of  microbial  origin 
in  a  fissure  of  the  nipple,  or  more  rarely  in  the  areola  and  is  in- 


488  THE    BREAST. 

fected  bv  the  saliva  of  the  suckling.  It  may  assume  three  forms: 
lymphangitis,  erysipeloid  or  abscess. 

Lymphangitis.  The  infection  occurs  at  a  single  point  and 
reaches  a  lymphatic  vessel,  which  shews  red  and  painful  lines  un- 
der the  skin  and  directed  towards  the  axillary  glands,  which  are 
sensitive.  This  episode  is  repeated  several  times  during  the  course 
of  lactation,  and  usually  affects  the  same  lymphatic  trunk.  The 
evolution  is  that  of  a  local  benign  erysipeloid. 

Erysipeloid.  The  infection  is  dift"use  around  the  nipple;  the 
whole  areola  is  red,  hot  and  painful,  and  the  suction  of  the  infant 
is  very  distressing.  There  is  a  short  febrile  attack  lasting  for  36 
hours.  Defervescence  occurs  with  disappearance  of  the  inflam- 
matory symptoms.  These  phenomena  are  nearly  always  recurrent 
in  the  course  of  the  same  lactation,  and  may  occur  5,  6  or  7  times 
at  intervals  of  15  days;  weaning  is  required. 

Abscess  of  the  breast.  This  forms  a  chapter  in  surgery,  and 
will  be  dealt  with  briefly  here.  Abscess  of  the  breast  may  develop 
insidiously  and  only  manifest  itself  by  painful  symptoms.  More 
commonly  it  follows  lymphangitis  or  erysipeloid.  Rarely  there 
is  a  single  abscess,  when  all  the  lymphatic  trunks  of  the  glands 
are  affected.  The  abscesses  occur  in  series,  in  the  midst  of  marked 
inflammatory  and  painful  symptoms,  developing  one  after  the 
other  and  necessitating  repeated  intervention.  They  may  only  oc- 
cur in  a  single  breast. 

Local  hygiene  after  each  suckling  diminishes  the  chances  of  in- 
fection. The  part  should  be  washed  with  saturated  boric  acid  in 
alcohol,  followed  by  the  application  of  sterile  glycerine.  The 
breast  should  be  covered  with  sterile  lint  or  wool  and  raised  by 
a  bandage,  or  a  simple  scarf  enclosing  the  dressing. 

After  the  first  local  phenomena,  moist  dressings,  aseptic  poul- 
tices, cleansing  of  the  nipple  and  areola  after  each  suckling,  and 
rest  in  bed  are  required,  and  prompt  surgical  intervention  if  an 
abscess  forms. 

The  same  treatment  applies  to  lymphangitis  and  to  erysipeloid. 
These  are  all  accidents  which  should  be  prevented  by  careful  at- 
tention to  fissures  of  the  nipple,  which  cause  all  of  them. 

FISSURE   OF  THE  BREAST. 

Fissures  of  the  breast  result,  during  lactation,  from  the  con- 
tinued  maceration   of  the   nipple   in   the   excreted   milk,   and   from 


THE    BREAST.  489 

the   traumatism   caused   by   the    efforts    of   suction   of   the    infant. 

It  is  necessary  to  bear  in  mind  that  the  aseptic  trait  of  animals 
is  impossible ;  that  the  external  infection  of  the  nipple  and  that 
of  the  galactophorous  ampulla;  in  all  animals  appears  to  be  con- 
stant; under  these  conditions  it  is  easy  to  understand  that  the  fis- 
sure may  be  semi-traumatic  and  semi-microbial,  and  that  it  may 
give  rise  to  the  different  complications  mentioned  above. 

The  saliva  of  certain  infants  may  be  acid,  or  keratolytic,  or  in- 
fected more  than  others.  Also,  certain  tissues  resist  badly  and  are 
easily  infected,  having  a  deficient  leucocytic  defence. 

These  causes  render  certain  women  more  subject  than  others  to 
fissures  and  their  consequences. 

The  treatment  of  fissues  is  prophylactic  and  curative.  The  ap- 
plication of  alcoholic  and  glycerine  lotions  after  each  suckling,  dress- 
ings of  glycerole  of  starch,  ointments  of  oxide  of  zinc  and  moist 
dressings  applied  over  the  ointment  on  the  least  sign  of  infection, 
constitute  the  best  methods. 

In  spite  of  all  treatment  a  fissure  may  increase  in  depth  and  menace 
the  integrity  of  the  nipples,  which  may  even  be  divided.  Under 
these  circumstances  lactation  must  be  suppressed. 


SYPHILITIC  CHANCRE. 

Chancre  of  the  breast  may  be  seen  in  women,  apart  from  wet 
nurses,  as  the  consequence  of  kissing  or  suction  by  a  syphilitic 
mouth.  In  wet  nurses  the  mouth  of  the  suckling  is  the  cause  of  the 
contamination. 

The  chancre,  usually  situated  on  the  nipple,  is  the  size  of  a  six- 
pence, oblong,  with  an  indurated  base  and  flat  shining  surface,  moist 
but  not  suppurating.  It  has  the  same  evolution  as  ordinary  chan- 
cre. Several  chancres  may  occur  on  both  breasts  or  on  the  same 
breast ;  the  first  in  date  is  generally  the  largest.  The  enlarged  axil- 
lary gland  is  never  absent,  and  no  other  affection  resembles  it. 

Local  induration  of  the  chancre  persists  long  after  its  disappear- 
ance and  may  give  evidence  of  a  former  lesion.  At  this  period  the 
skin  over  the  induration  is  purple  but  not  cicatricial. 

Syphilis,  consecutive  to  chancre  of  the  breast,  is  not  usually  of 
particular  severity.  It  requires  the  usual  treatment  and  determines 
the  same  lesions. 


490  THE    BREAST. 

When  syphilis  is  clearly  established  in  a  wet  nurse,  it  is  useless 
for  her  and  detrimental  to  the  child  to  remove  it,  since  the  harm  is 
already  done.  If  the  nurse  is  suckling  two  infants,  one  a  strange 
child  and  the  other  her  own,  it  is  evidently  necessary  to  ween  the 
latter.  It  may  have  escaped  infection,  for  it  often  happens,  when 
a  nurse  has  two  sucklings,  that  each  child  always  sucks  from  the 
same  breast.  I  cannot  enter  into  all  the  medico-legal  details  to  which 
such  an  accident  may  give  rise.  The  physician,  having  regard  to 
professional  secrecy  in  all  cases,  should  try  to  avoid  communication 
of  the  disease  by  the  nurse,  acquired  from  the  suckling,  to  her  own 
husband  or  to  others. 


SECONDARY  SYPHILIS. 

Secondary  syphilis  of  the  breast  includes  roseola,  which  is  often 
very  pronounced  on  the  chest,  but  general  on  the  body;  a  more  or 
less  abundant  eruption  of  flat,  deep  red,  secondary  papules,  which 
are  not  more  marked  on  the  breast  than  elsewhere;  in  severe  sec- 
ondary syphillis  ulcerating  papules,  "ecthyma  or  syphilitic  rupia," 
may  occur,  but  not  more  often  than  in  other  parts.  Mucous  patches 
may  occur  in  the  wet  nurse,  on  or  around  the  nipple,  in  all  the  re- 
gion which  is  macerated.      (For  treatment  of  syphilis,  see  p.  650.) 


HYDRADENOMA. 

Eruptive  hydradenomata  form,  on  the  chest  in  general  and  on 
the  breasts,  an  eruption  of  lenticular  yellowish  red  spots,  slightly 
grey  and  raised.  A  small  tumour  the  size  of  a  grain  of  barley  is 
felt  in  the  skin,  by  pressure  between  the  fingers.  This  eruption  de- 
velops slowly  and  is  only  noticed  accidentally,  having  no  local  signs 
(p.  630). 

ACNE. 

There  is  no  form  of  acne  peculiar  to  the  breast,  but  acne  may  oc- 
cur on  the  breast  when  also  affecting  the  chest  and  medio-thoracic 
region  (p.  477). 


THE  BREAST. 
ECZEMA  OF  THE  BREAST. 


491 


The  old  doctrines  stated  that  eczema  of  the  breast  had  three 
causes :  scabies,  pregnancy  and  scrofula.  The  third  cause  was 
invoked  when  the  two  others  were  absent ;  and  as  this  was  not 
strictly  defined,  it  could  not  be  refuted. 

Eczema  of  the  breast  is  practically  always  a  streptococcic  epi- 
dermatitis.  (For  methods  of  culture  see  p.  8).  It  is  generally 
limited  to  the  areola,  which  is  pink,  exudative  and  covered  with 
amber  coloured,  crystalline,  crackled  crusts. 


jjy'-"  ■•''  ""■'•^•^^  ^*^?i'-MS^Mc*^^^>-r^  ''  \^s 


Figr.  199.     Eczema  of  the  nipple. 
(Devergie's  patient.     St.   Louis  Hosp.   Museum,    No.    160.) 

The  subjacent  dermatitis  is  marked  by  permanent  redness,  and 
the  axillary  glands  may  be  enlarged. 

Scabies  must  be  looked  for  in  its  usual  localisations,  and  the 
characters  of  the  elementary  lesions  examined.  If  scabies  is  elim- 
inated, pregnancy  must  be  looked  for,  and  is  easy  to  prove,  for 
eczema  of  the  breast  seldom  occurs  before  the  fourth  or  fifth 
month. 

Local  treatment  is  the  same  in  all  cases;  but  when  scabies  is  the 
cause  of  the  eczema  it  also  requires  treatment.     The  areola  should 


492  THE    BREAST. 

be  painted  with  nitrate  of  silver  (lo  per  cent),  and  covered  with 
oxide  of  zinc  ointment  (i  in  4).  Starch  poultices  render  the  cau- 
terisation less  painful.  When  the  irritation  has  subsided,  weak 
oil  of  cade  ointments  may  be  applied : — 

Oxide   of  zinc 1      ,^         grammes   ISiiss 

Oil  of  cade J  J 

Va^^''"« 1  aa  IS  "  r3i 

Lanoline J  •' 

Eczema  of  the  breast  is  very  chronic,  even  when  its  exciting  cause 

is  removed,  such  as  scabies.     Recurrence  is  frequent  and  must  be 

carefully  treated. 


SCABIES. 

Scabies  of  the  breast  presents  its  usual  lesions,  as  in  other  regions ; 
burrows,  vesicles  and  excoriations. 


Fig.  200.     ruPtular   and    eczematous    scabies    of    the    breast. 
(Fournier's   patient.      St.    Louis    llosp.    Museum.      No.    1759.) 


It  may  be  complicated  by  divers  lesions  caused  by  scratching, 
and  determine  a  so-called  eczema  of  the  breast,  which  is  a  strepto- 


THE    BREAST.  493 

coccic  epidermatitis  of  the  areola.  This  is  common,  and  the  breast 
assumes  a  peculiar  appearance  with  its  impetiginous  areola  and  exu- 
dative, yellow  crusted  surface,  surrounded  by  the  scattered  lesions 
of  scabies. 

This  clinical  picture  is  typical,  and  is  completed  by  examination 
of  the  axillary  regions  and  the  hands  (pp.  257  and  344).  I  have 
described  the  treatment  of  eczema  of  the  breast  caused  by  scabies 
(p.   492).      The  treatment  of  the   scabies   is  the  same  as  usual 

(P-  537)- 

SUB-MAMMARY  INTERTRIGO- 

Except  in  young  girls,  there  is  nearh-  always  in  the  female  a  sub- 
mammary fold,  more  or  less  marked  according  to  the  size  of  the 
breast  and  the  age  of  the  subject.  This  fold,  which  is  comparable  to 
the  folds  of  flexion,  presents  the  parasitic  affections  of  these  folds, 
and  also  intertrigo,  especially  in  fat  women.  This  intertrigo,  like 
the  others,  is  always  streptococcic  at  first.  It  may  be  unilateral,  but 
is  more  often  bilateral.  If  neglected  its  physical  causes  persist  and 
it  remains  in  a  chronic  state.  It  often  co-exists  with  intertrigo  of 
other  natural  folds. 

Treatment  consists  in  (i)  maintaining  the  breasts  permanently 
raised  by  means  of  a  scarf;  (2)  local  friction  with  solution  of  nitrate 
of  silver  (i  in  15);  (3)  the  application  of  oxide  of  zinc  and  oil  of 
cade  ointment,  applied  after  each  friction  with  nitrate  of  silver  and 
washed  off  before  it.  Recurrence  is  to  be  expected  if  the  breasts 
are  not  kept  elevated. 

SUB-MAMMARY   TRICHOPHYTOSIS. 

This  is  the  same  trichoph}i;sois  which  I  have  described  in  the 
fold  of  the  groin  (p.  266),  and  I  have  never  seen  it  in  the  sub- 
mammary region  without  its  first  occurring  in  the  groin. 

It  forms  a  red,  moist  patch,  exactly  intertriginous,  but  bordered 
with  a  red  margin,  in  which  fine  vesicles  are  visible.  This  lesion 
may  be  mistaken  for  intertrigo,  but  is  never  streptococcic.  Cul- 
ture from  scrapings  of  the  horny  epidermis  shows  the  same  parasite 
as  in  inguinal  and  axillary  trichoph>i:osis,  and  no  streptococci. 

Treatment  is  the  same  as  for  inguinal  trichophytosis,  by  alternate 
applications  of  fresh  tincture  of  iodine  in  60  per  cent  alcohol  (20 
per  cent),  and  oxide  of  zinc  ointment  (i  in  4).  If  the  lesion  is 
rebellious,  chrysarobin,  2  per  cent,  may  be  added  to  the  ointment. 


494  THE   BREAST. 

LUPUS.     TUBERCULOSIS. 

Lupus  of  the  breast  is  not  common  and  presents  no  particular 
evolution  or  symptoms.  Both  tuberculous  lupus  and  lupus  erythe- 
motosus  may  occur,  and  the  reader  may  refer  to  what  I  have  said 
concerning  these  affections  on  the  face  (p.  i8). 

Tuberculosis  of  the  breast,  on  the  contrary,  is  a  very  special 
affection,  although  rare,  and  requires  a  short  description.  It  arises 
in  the  form  of  a  very  irregular,  lobulated,  digitated,  mammillated 
tumour,  in  the  substance  of  the  sub-cutaneous  adipose  tissue.  Seen 
by  transparency  it  appears  blue  and  not  adherent  to  the  skin.  It 
may  be  accompanied  by  enlarged  axillary  glands.  It  is  sensitive 
to  touch  and  painful  on  pressure,  but  not  spontaneously  painful. 
After  several  months  the  tumour  becomes  fixed  to  the  skin,  which 
ulcerates ;  the  ulceration  soon  becomes  deep  and  ragged,  with 
detached  borders  and  a  fungus  surface,  discharging  grumous,  tuber- 
culous pus.     The  ulceration  is  very  painful. 

The  patient  is  generally  cachectic  from  phthisis,  and  dies  of  pul- 
monary tuberculosis. 

The  treatment  varies  in  different  cases.  Excision  of  the  whole 
tumour,  before  it  has  ulcerated,  appears  to  be  indicated.  At  the 
same  time  general  treatment  of  the  tuberculosis  is  required. 

GUMMA  OF  THE  BREAST. 

Syphilitic  gumma  of  the  breast  is  rare.  It  is  generally  normal  as 
regards  evolution  and  symptoms.  A  tumour  of  medium  size  arises 
under  the  skin,  and  becomes  fixed  to  it  as  it  develops;  the  skin 
becomes  red  and  purple  and  ulcerates,  exposing  a  granular  mass 
which  gradually  extends  and  becomes  excavating. 

The  diagnosis  of  syphilis  is  made  by  corroborative  evidence,  and 
by  the  absence  of  the  general  signs  of  tubercle;  objectively,  by  the 
rounded  form  of  the  gumma,  by  the  edges  not  being  detached,  by 
the  redness  around  the  ulcer,  which  is  round  and  regular;  also  by 
the  absence  of  marked  functional  symptoms.  The  therapeutic  test 
is  decisive  and  should  never  be  neglected  in  doubtful  cases. 

FACET'S  DISEASE  OF  THE  NIPPLE. 

This  is  a  rare  specific  disease;  non-contagious,  unilateral,  chronic 
and  occurring  almost  exclusively  in  women  between  the  ages  of  35 


THE    BREAST.  495 

and  50;  constituted  in  its  first  stage  by  the  production  of  small 
horny  elevations  covering  small  progressive  ulcerations  on  the  sum- 
mit of  the  nipple.  The  nipple  gradually  retracts  and  disappears,  and 
the  lesion  extends  slowly  on  the  areola  and  neighbouring  skin  with- 
out ever  retrogressing  or  healing.  In  its  mature  stage  the  diseased 
surface  presents  a  clear  polycyclic  border,  slightly  raised  and  squa- 
mous; a  red  surface,  excoriated  or  ulcerated,  crusted  and  strewn 
with  epidermised  points  (Darier).  The  duration  of  the  disease  is 
counted  by  years ;  it  always  remains  unilateral  and  develops  very 
slowly.  The  exulceration  presents  a  slight  papyraceous  induration. 
The  lesions  are  not  modified  by  any  ordinary  treatment.  They 
are  not  accompanied  by  enlargement  of  the  axillary  glands.  At 
a  third  stage,  which  may  arise  after  5  to  20  years,  the  ulcerative 
cancerous  phase  of  the  disease  supervenes.  The  superficial  ulcera- 
tion may  become  deep  and  infiltrating ;  or  a  tumour  may  arise  in  the 
deeper  parts  and  implicate  the  skin.  The  glands  then  become 
afifected  and  the  disease  develops  as  a  cancer. 

The  characteristic  feature  of  the  disease  is  the  presence  of  cellu- 
lar elements,  pseudo-coccidia,  enclosed  between  the  normal  epi- 
dermic cells.  These  are  round  or  oval  bodies  with  a  double  out- 
line, usually  much  larger  than  the  normal  horny  cells  which  enclose 
them  (Darier).  These  bodies  may  be  seen  by  treating  the  squame 
with  a  solution  of  potash  (40  per  cent),  and  examining  without 
staining. 

The  treatment  of  Paget's  disease  should  now  be  by  radiotherapy; 
formerly  it  was  treated  like  benign  epitheliomas  of  the  face,  by 
curetting  or  caustics ;  arsenious  acid,  etc.  In  the  third  stage  it  must 
be  treated  as  a  cancer.  I  have  treated  one  case  with  H.  Noire  by 
radiotherapy,  which  resulted  in  a  cure  in  7  months,  without  recur- 
rence. 

TUMOURS  OF  THE  BREAST. 

Tumours  of  the  breast  do  not  belong  to  dermatology  when  they 
arise  in  the  deeper  parts,  which  is  the  rule.  A  process  of  evolution, 
which  advances  every  day,  will  no  doubt  lead  to  the  inclusion  of 
many  of  the  former  surgical  tumours  of  the  breast  among  derma- 
tological  diseases,  owing  to  the  results  of  radiotherapy.  For  the 
time  being  the  dermatologist  will  be  prudent  to  submit  to  the  sur- 


496  THE    BREAST. 

geon  every  tumour  of  the  breast,  of  which  the  benignity  or  malignity 
is  doubtful. 

If  the  surgeon  can  wait  two  months  before  intervening,  the 
tumour  should  be  treated  at  once  with  X-rays,  according  to  the 
rules  given  by  H.  Noire;  that  is,  3  or  4  consecutive  sittings  every 
15  days;  one  above,  one  below,  one  internal  and  one  external  to  the 
breast,  so  that  each  application  is  made  on  a  different  surface  of 
skin,  and  directed  by  the  metallic  cylinder  towards  the  tumour. 
Each  application  should  be  of  the  tint  B  of  the  radiometer  of  Sabou- 
raiid  and  Noire.  It  is  necessary  to  treat  the  glands  of  the  axilla 
with  the  rays  every  time  an  application  is  made  on  the  skin.  If, 
after  four  sittings,  performed  in  this  way,  the  tumour  is  not  sensibly 
reduced,  an  operation  should  be  performed. 

If  the  surgeon  does  not  advise  waiting  for  2  months,  the  tumour 
should  be  removed  at  once,  and  radiotherapy  of  the  cicatrix  should 
be  performed  afterwards,  by  5  or  6  sittings,  each  of  the  tint  B  of 
the  radiometer,  with  intervals  of  18  to  20  days  between  the  sit- 
tings. It  is  well  to  bear  in  mind  that  some  sarcomas  give  less  cer- 
tain results  than  epitheliomas,  especially  when  they  are  operated  upon 
late.  The  therapeutic  value  of  the  X-rays  will  be  settled  eventually, 
but  the  results  hitherto  obtained  are  encouraging. 

CHORIO-EPITHELIOMATOSIS.     CANCER  IN  CUIRASS. 
CANCEROUS    LYMPHANGITIS. 

In  certain  rare  cases  the  skin  is  uniformly  affected  with  a  diffuse 
epitheliomatosis,  which  thickens  the  skin  so  that  it  cannot  be  readily 
pinched  up.  The  skin  is  hard  and  infiltrated ;  of  a  reddish  yellow 
colour  and  marbled ;  and  the  affected  surface  is  limited  by  a  clearly 
defined  irregular  margin.  This  condition  occurs  round  a  cancerous 
ulceration  of  the  breast,  or  over  a  central  tumour,  with  retraction 
of  the  nipple.  Diagnosis  may  be  difficult  and  is  made  chiefly  by 
exclusion. 

Surgical  treatment  is  unsuccessful,  and  there  is  often  recurrence 
In  the  cicatrix  before  it  is  complete.  Radiotherapy  should  be  tried 
according  to  the  rules  formulated  in  the  preceding  paragraph. 

Cancerous  Lymphangitis.  Under  the  same  conditions  as 
chorio-epitheliomatosis,  one  or  more  cancerous  lymphangites  may 
occur.    These  are  hard  to  the  touch,  raised  under  the  skin,  nodular 


THE    BREAST.  497 

and  moniliform  and  directed  towards  the  axillary  glands,  which  are 
often  affected. 

Good  results  have  been  obtained  in  these  cases  by  radiotherapy 
(Bed  ere). 

Schirrus  en  cuirasse.  This  is  an  epitheliomatous  transforma- 
tion of  the  skin,  in  which  small,  nodular  raised  tumours,  on  a  schir- 
rus cuirass,  are  covered  with  an  adherent  but  normal  skin,  with  no 
tendency  to  ulceration.  Treatment  is  the  same  as  for  the  preceding 
form. 


32 


THE  UMBILICUS. 


In  the  pathological  physiology  of  the  skin  the  umbilicus  should 
be  placed  with  the  folds  of  flexion,  to  which  it  presents  morbid 
affinities.     I  shall  studv  successively: — 


First,  erysipelas  of  the  ncu^ly-born  zvkich  arises  j'm"1  Erysipelas    of    the 
the  navel  and  presents  severe  characters J      newly-born  .  .  . 

Next,  the  intertrigo  zvhich  is  seen  in  persons  with 
a  deep  umbilical  cicatrix  and  zvho  neglect  local 
hygiene 

/  shall  next  consider  pityriasis  with  fatty  squames, 
and  the  so-called  seborrhccic  eczema  of  Unna, 
which   may  cause   nummular  intertriginous  lesions 


.  p.  498 
Intertrigo p.  499 

-Steatoid    pityriasis  p.  499 


.  .  .  and  steatoid  psoriasis,  zchich  has  the  same 
election  for  surfaces  of  thin  skin  and  the  natural 
folds 


Psoriasis 


p.  500 


syph- 


/    shall    conclude    zcith    the   secondary    syphilitic!  Secondary- 
lesions,  which   may  be   concealed  in   the  umbilicus^      ills p.  500 

.  .  .  and  the  pruriginous  and  excoriated  lesions 
zi'ith  zchich  it  is  often  surrounded  in  the  course  of 
scabies 


Scabies p.  501 


PERI-UMBILICAL  ERYSIPELAS  OF  THE  NEWLY-BORN. 

Peri-umbilical  erysipelas  of  the  newly-born  is  nearly  always  con- 
secutive to  an  umbilical  infection,  during  the  first  days  after  birth. 
It  may  be  peri-umbilical  or  lateral,  and  sometimes  appears  to  arise 
not  near  the  umbilicus,  but  on  the  genital  organs  or  pubes.  It  is 
generally  an  ambulatory  erysipelas,  and  its  objective  characters  are 
those  of  erysipelas  in  general ;  a  red  irregular  placard,  in  the  region 
of  which  the  skin  is  shiny,  thickened,  tense,  (Edematous  and  painful. 
When  the  erysipelas  affects  a  region  with  loose  cellular  tissue  the 
cedema  becomes  enormous.  The  temperature  is  raised  to  40-41°  C. ; 
the  infant,  who  shows  no  general  symptoms,  ceases  to  suck  and 
death  often  occurs  from  rapid  collapse.  The  prognosis  of  erysipe- 
las at  this  age  is  very  bad ;  nevertheless  the  longer  the  disease  lasts, 
the  greater  the  chance  of  recovery.    Multiple  streptococcic  abscesses 


THE    UMBILICUS.  499 

then  develop,  which  have  been  called  curative.    Death  may,  however, 
supervene  even  in  cases  where  these  occur. 

Umbilical  erysipelas  should  be  avoided  by  asepsis  of  the  wound 
of  the  cord  and  the  region  around  it.  There  is  no  treatment  proper, 
but  applications  of  colloidal  silver  may  be  tried,  and  wet  dressings 
•diminish  congestion  and  local  temperature. 

UMBILICAL  INTERTRIGO. 

Umbilical  intertrigo  may  occur  in  coincidence  with  intertrigo  of 
all  the  other  folds,  or  may  exist  alone.  It  is  accompanied  by  an 
accumulation  of  epidermic  debris  at  the  bottom  of  the  folds  and  is 
generally  favoured  by  a  deep  and  retracted  umbilical  cicatrix.  It 
may  be  confounded  with  eczematised  steatoid  pityriasis,  or  eczema 
of  the  folds  (p.  12). 

When  the  diagnosis  is  certain  the  patient  should  perform  regular 
soaping  of  the  region.  Nitrate  of  silver  (i  in  20  to  i  in  10)  and 
oxide  of  zinc  ointment  ( i  in  4)  may  be  applied.  Whenever  local 
eczematisation  is  set  up,  an  equal  quantity  of  oil  of  cade  should  be 
added  to  the  ointment. 

STEATOID  PITYRIASIS    (SEBORRHOEIC  ECZEMA  OF  UNNA). 

On  the  scalp  pityriasis  capitis  may  become  eczematised  (p.  215). 
The  eczema  which  results  (SeborrhcEic  of  Unna),  may  form  moist, 
yellow,  squamo-crusted  patches  in  all  the  regions  where  the  skin  is 
thin,  the  natural  folds,  etc.  The  question  whether  this  eczematous 
form  is  always  consecutive  to  a  pre-existing  pityriasis  is  contro- 
versial, and  need  not  detain  us. 

Clinically,  this  morbid  type  may  occur;  (i)  as  recurrent  nummular 
placards  of  the  same  nature  as  on  the  scalp;  (2)  behind  the  ear, 
complicating  a  fissured  streptococcic  intertrigo;  (3)  in  the  normal 
folds,  or  in  dififerent  parts  of  the  body,  always  in  the  same  form. 

Treatment  comprises  oil  of  cade  ointments  of  different  strengths : 

(0  Oil  of  Cade T 

Oxide  of  zinc J         ^''^5  grammes  3ii  ss 

Ichthyol    ] 

Resorcine L       aa     I  gramme  3ss 

Oil  of  Birch j 

Lanoline 

Vaseline 


J        aa  IS  grammes  5j 


aa  10  grammes 

Bj 

2  grammes 

Biss 

aa     I  gramme 

gr.  48 

Soo  THE    UMBILICUS. 

(2)  Oil  of  Cade 

Lanoline 

Vaseline , 

Oil  of  Birch 

Resorcine 

Turpeth    mineral    .    .    . 

Pyrogallic  acid 75  centigrammes  gr.  36 

The  ointment  should  be  washed  off  with  soap,  10  to  15  hours  after 
appHcation. 

PSORIASIS. 

Psoriasis,  with  a  tendency  to  occur  in  the  folds,  often  presents 
patches  with  yellow  and  fatty  squames  which  appear  seborrhoeic. 
We  have  already  met  with  this  form  of  psoriasis  in  several  regions 
(pp.  476  and  481).  In  the  umbilicus,  the  fold  which  is  most  con- 
stantly closed,  it  is  most  difficult  to  cure. 

It  occurs  in  the  form  of  a  tawny  red  placard,  with  thickening  of 
the  skin,  and  the  production  of  yellow  semi-fatty  scabs. 

It  may  be  treated  by  oil  of  cade  ointments,  weak  or  strong,  as 
above;  or,  if  these  do  not  succeed,  by  the  following: — 


aa     I  gramme 


gr.  32 


Chrysarobin 

Resorcine 

Ichthyol    

Yellow   oxide   of   Mercury 

Oil  of  Birch 2     grammes         5j 

Oil  of  Cade 10  grammes      3v 

Lanoline 


,,       ,.  h    ^^  ^S  grammes     [  5j 

Vasehne J  -J 

This  should  be  soaped  off  before  each  fresh  application. 


SYPHILIS. 

In  the  course  of  a  florid  eruption  of  secondary  syphilis,  exulcer- 
ating  papules  may  occur  in  the  umbilicus,  having  the  appearance  of 
the  commissural  mucous  patches  of  the  lips.  Such  cases  are  not 
common  and  only  constitute  an  epiphenomenon  in  the  course  of  a 
general  papular  eruption. 


THE  UMBILICUS.  Sol 

SCABIES. 

The  acarus  of  scabies  often  has  a  predilection  for  the  peri-um- 
bilical region.  The  burrows  are  always  few  in  number  and  mixed 
with  erosions  caused  by  scratching,  broken  vesicles  and  accessory 
lesions  of  secondary  prurigo. 


THE   FLANKS. 

The  flanks  present  very  few  special  cutaneous  lesions. 

/  shall  describe  liiiece  albicantcs  because  they  are^ 
more  common  and  of  greater  importance  on  the  ab-  rLinese   albicantes   p.  502 
domen  than  elsewhere,  especially  in  women  .    .    .J 

Also  lichen  scrofulosorum;  not  that  this  eruption' 
of  tuberculides  is  exclusive  to  this  region,  for  it 
occurs  in  all  others,  but  because  it  seldom  fails  to 
present  its  maximum   lesions  on  the  Hanks   .    .    . 


Lichen    scrofulo- 
sorum    ....   p.  503 


All  the  general  dermatoses  might  be  described  on  the  flanks; 
scabies,  prurigo,  eczema,  roseolas,  etc. ;  but  I  prefer  to  limit  the  last 
regional  chapters,  as  far  as  possible,  because  to  attribute  to  them  a 
larger  place  in  dermatology  would  overstep  clinical  experience;  the 
dermatoses  which  are  generalised  on  the  whole  body  or  trunk  will 
have  their  peculiar  characters  mentioned  later  (p.  515). 


LINEAE  ALBICANTES, 

These  may  occur  at  all  parts  where  the  skin  has  been  much  dis- 
tended, and  where  this  distention  has  ceased  to  exist.  Thus,  increase 
in  the  size  of  a  limb  or  of  a  region  may  produce  them;  at  the  root 
of  the  thighs,  on  the  breast,  for  example.  They  are  most  common 
on  the  abdomen  in  women  during  pregnancy.  They  result  from 
rupture  of  the  elastic  layer  of  the  dermis  during  distention.  When 
the  skin  is  relaxed  they  feel  like  furrows  in  the  skin,  leading  to  the 
subcutaneous  adipose  tissue. 

Linese  albicantes  are  thus  smooth  permanent  cicatrices.  They 
occur  in  all  degrees,  from  long,  narrow  iridescent  bands,  level  with 
the  skin,  and  marking  the  abdomen  like  a  zebra,  up  to  lesions  as 
large  as  the  thumb,  divided  into  meshes  by  elastic  strands,  through 
which  the  subjacent  tissues  may  pass,  as  in  eventration. 

These  lesions  depend  more  on  the  quality  and  nature  of  the 
tissues  than  on  the  degree  of  distention.  Brown  skins,  which 
usually  fold  thinly,  are  much  less  affected  than  fleshy  blonde  skins, 
which  fold  thickly.  It  appears  that  skins  affected  with  certain 
morbid  conditions,  such  as  keratosis  pilaris  of  the  back  of  the  arms, 


THE    FLANKS. 


S03 


chilblains,  etc.,  are  more  predisposed  than  others  to  cause  large  and 
disfiguring  linese  albicantes.    Also,  in  the  absence  of  any  distention 


Fig.  201.     Lineae    albicantes    of    the    flank    after    typhoid    fever. 
(Besnier's    patient.      St.    Louis    Hosp.    Museum.      No.    1275.) 


they  may  be  produced  after  fevers,  such  as  typhoid,  scarlatina,  vari- 
ola, etc. 

LICHEN    SCROFULOSORUM. 


This  is  a  lichenoid  eruption,  occurring  in  disseminated  groups,  on 
the  whole  or  part  of  the  body,  in  tuberculous  or  scrofulous  subjects, 
generally  during  adolescence. 

Objectively,  the  eruption  is  composed  of  small  polymorphous  ele- 
ments ;  some  identical  with  the  papules  of  prurigo,  flat,  reddish  yel- 
low and  grouped  like  islands  in  an  archipelago ;  others  with  a  fol- 
licular centre,  resembling  an  abortive,  non-suppurating  folliculitis; 
sometimes  with  a  crust  in  the  follicular  orifice.  At  other  times  the 
lichenoid,  or  peri-follicular  acuminations,  form  figured  lesions ;  cir- 
cles or  semi-circles.  In  these  cases  it  appears  that  the  empty  circle 
is  produced  by  the  disappearance  of  elements  earlier  in  date,  which 
have  left  no  trace. 

The  groups  of  lesions  of  lichen  scrofulosorum  are  more  or  less 
numerous,  and  there  may  be  only  lo  or  12  on  the  whole  body.  After 
the  flanks,  the  regions  most  often  aflfected  are  the  forearms,  shoul- 
ders and  back. 


SPA 


THE    FLANKS. 


The  distribution  of  lesions  is  quite  irregular  and  does  not  corre- 
spond to  any  schematic  topographical  plan.  The  lesions  often  arise 
suddenly,  in  one  or  two  weeks,  without  any  appreciable  functional 
or  general  symptoms,  in  tuberculous  subjects.  Sometimes  they 
occur  after  a  sub-acute  crisis  of  pulmonary  or  peritoneal  tuberculosis, 
or  during  the  course  of  a  visceral  tubercle,  or  after  surgical  opera- 
tions for  tuberculous  glands  in  the  neck,  axill?e,  etc. ;  sometimes  with- 
out any  apparent  cause  ;  but  the  relation  of  lichen  scrofulosorum  with 
tuberculosis  is  so  evident  that  it  was  the  first  clinical  type  of  tuber- 
culides clearly  recognised  in  dermatology. 


THE  SACRAL  REGION. 


Pruritus 


P-50S 


The  sacral  region  is  peculiar,  in  that  many  of  the  dermatological 
lesions  met  with  have  a  resemblance  to  each  other,  possibly  because 
they  are  only  varieties  of  a  single  morbid  type. 

Local  pruritus  is  common,  from  whatever  cause' 
it  arises,  whether  idiopathic,  or  secondary,  or 
zclicther  it  belongs  to  the  pruriginous  state  of  a 
definite  dermatosis 

Tlie  old  lichens  or  prurigos,  the  placards  of  lich- 
enisation  and  eczematisation,  are  often  allied  to 
pruritus,  in  the  course  of  which  they  frequently 
arise 

The  placards  of  lichenisation  may  become  ec- 
sematised,  or  placards  of  eczema  may  follow  an  in- 
tertrigo of  the  intergluteal  fold 

Psoriasis,   in   the   sacral  region,   may   form   red,' 
thick,   squamous,   pruriginous   placards,    the    diag- 
nosis  of  which  is   made   by    the   concomitance   of 
lesions  in  the  elective  regions  of  the  disease  .    .    . 

Lastly,  I  shall  mention  briefly  the  congenital  mal- 
formations of  the  region;  spina  bifida,  dermoid 
cysts,  and  hairy  ncevi,  which  have  no  dermatological 
or  therapeutic  importance 


Lichen.  Lichenisa- 
tion   p.  506 

Eczema.     Ecze- 
matisation  ...   p.  506 


-Psoriasis p.  507 


Spina  bifida,  der- 
moid cysts,  hairy 
naevi p.  508 


PRURITUS. 


The  sacral  region  is  one  where  pruritus  of  divers  causes  is  fre- 
quently localised.  Sometimes  there  is  a  pruritus  without  lesions, 
generally  in  old  people  (p.  551),  or  there  may  be  pruritus  accom- 
panied by  cutaneous  thickening,  with  or  without  hyperchromia 
( p.  546) ,  Sometimes  the  pruritus  is  accompanied  by  the  excoriated 
papular  lesions  of  prurigo,  or  by  a  certain  degree  of  eczematisation 
(p.  547).  Lastly,  the  pruritus  may  create  patches  of  lichenisation 
(p.  548),  or  so-called  neuro-dermatitis. 

All  this  may  occur  in  idiopathic  pruritus,  the  cause  of  which  is 
obscure  (p.  546),  and  appears  to  vary  in  different  cases.  But  it 
may  also  be  observed  in  the  first  stage  of  mycosis  fungoides  (p.  637) , 
and  it  is  important  to  diagnose  this  condition,  which  requires 
active  radio-therapeutic  intervention.  In  this  case  a  biopsy  is  often 
required. 


5o6  THE   SACRAL    REGION. 

In  all  these  cases  the  pruritus  is  not  exclusively  localised  to  this 
region,  but  is  more  or  less  marked  on  the  back,  the  flanks  and  but- 
tocks; but  it  is  often  more  severe  in  the  sacral  region,  and  consti- 
tutes the  lesions  which  we  have  mentioned  above. 

The  general  treatment  of  pruritus  varies  according  to  the  cause; 
the  local  treatment  comprises  the  series  of  anti-pruriginous  appli- 
cations; glycerin,  resorcin  (i  in  30);  carbolic  acid  (i  per  cent); 
menthol  (i  per  cent)  ;  X-ray  applications  (half  tint  B),  and  high 
frequency,  etc. 

LICHEN.     LICHENISATION.     NEURO-DERMATITIS. 

A  more  or  less  pronounced  local  pruritus  may  gradually  transform 
the  skin  of  the  region  and  create  placards  of  chronic  irritation,  of 
the  type  formerly  called  lichens  and  chronic  eczemas;  but  which 
are  now  designated  lichenification,  or,  hypothetically,  neuro-derma- 
titis. 

They  consist  of  round,  oblong  or  indistinctly  polygonal  placards, 
composed  of  thickened,  hard,  finely  quadrillated  skin,  forming  con- 
tiguous lozenge  shaped  areas.  Sometimes  the  surface  of  these  areas, 
which  is  grey,  smooth,  flat  and  shining,  gives  the  appearance  of  the 
lichenification  of  Brocq  (Fig.  209.  p.  547).  Sometimes  the  placards 
are  excoriated  by  scratching,  red,  moist,  and  presenting  here  and 
there  a  fine  powder  of  yellow  crystalline  crusts. 

This  is  the  old  lichen  circumscriptus  of  Vidal,  which  we  have  met 
with  in  divers  regions  (p.  172),  and  which  is  always  accompanied 
by  intense  pruritus.  According  to  some  authors  the  pruritus  pre- 
exists, and  the  lesion  is  due  to  scratching;  according  to  others  the 
lesion  causes  the  scratching,  which  modifies  and  complicates  it. 

All  local  anti-pruriginous  treatment  of  pruritis  is  unsatisfactory. 
Zinc  paste,  or  plasters  of  cod-liver  oil  sometimes  succeed ;  but  oil  of 
cade  ointments  have  always  given  me  the  best  results,  the  formula 
being  modified  according  to  the  susceptibility  of  the  skin. 


ECZEMA  CONSECUTIVE  TO  GLUTEAL  INTERTRIGO. 

Intertrigo  of  the  gluteal  fold  (p.  452)  is  prolonged  upwards  as 
far  as  the  sacral  region,  and  may,  in  certain  cases,  terminate  in  a 
placard  of  chronic,  red.  psoriasiform  eczema,  which  is  most  tena- 


THE   SACRAL    REGION.  507 

cioiis  and  difficult  to  cure.  This  rounded,  semilunar  patch,  of  varia- 
ble size,  resembles  a  lichenised,  eczematised  placard  (p.  561),  but  is 
more  level,  and  more  uniformly  red.  The  crust  is  flat,  and  adherent, 
and  when  removed  reveals  fissures  which  bleed  easily.  This  lesion 
is  very  similar  to  the  one  previously  described,  and  hardly  differs  in 
treatment ;  but  it  is  secondary  to  an  intertrigo  of  the  gluteal  fold. 

The  intertrigo  itself  participates  in  the  lichenisation  and  the  skin 
of  the  gluteal  fold  is  often  h3'^pertrophied  and  fissured. 

Oil  of  cade  applications  are  useful  in  this  case: — 

Oil  of  Cade 1  ^    .. 

r\     A        c     ■  I  aa     5  grammes       yon  ss 

Oxide   of  zinc J  -^  ^  j 

Ichthyol 

Resorcine }-  aa     i  gramme         }.    gr.  32 

Oil  of  Birch 


Vasehne T 

T         1-  raa.  15  grammes 

Lanoline J 


3] 


Plasters  of  cod-liver  oil,  oxide  of  zinc,  or  cinnabar,  or  more  active 
ones,  with  salicylic  acid,  pyrogallic  acid  (10  per  cent)  may  also 
render  good  service  in  rebellious  and  recurrent  cases. 

PSORIASIS. 

The  elements  of  psoriasis  in  this  region,  when  they  occur  other- 
wise than  as  an  epiphenomenon  in  the  course  of  a  general  psoriasis, 
closely  resemble  the  lesions  described  in  the  preceding  paragraphs. 
A^ll  these  lesions  of  chronic  dermatitis  have  a  resemblance  in  the 
sacral  region.  However,  the  elements  of  psoriasis  are  more  regu- 
larly rounded  and  nummular;  their  surface  is  more  level  and  their 
papyraceous  squame  is  thicker,  drier  and  more  scaly.  But  it  is 
after  examination  of  other  lesions  on  the  body  (the  elbows  and 
knees,  and  isolated  patches  on  the  trunk)  that  the  diagnosis  is 
finally  established. 

The  treatment  is  that  of  rebellious  psoriasis,  with  strong  oint- 
ments : — 

Pyrogallic  acid  .... 

Turpeth   mineral   .   .   •    •    |.aa     i  gramme        j.  gr.  24 

Resorcine 


Chrysophanic   acid   ...  30  centigrammes     gr.     8 

Lanoline 

Oil  of  Cade   .... 


raa  20  grammes     r  3j 


So8  THE   SACRAL   REGION. 

Treatment  by  chrysarobin  and  traumaticin  is  also  practical,  and 
well  borne  by  patients.  A  solution  of  chrysarobin  in  chloroform  (5 
per  cent)  is  painted  on  the  lesions,  and  covered  with  traumaticin. 

CYSTS.    HAIRY  NAEVI.    SPINA  BIFIDA. 

The  possible  existence  of  the  following  conditions  in  the  region 
of  the  coccyx  may  be  mentioned :  dermoid  cysts ;  spina  bifida ;  tufts 
of  hairs  of  the  same  embryonic  origin  as  the  dermoid  cysts.  All 
these  are  congenital  malformations  which  need  not  detain  us;  the 
last  because  they  require  no  treatment ;  the  others  because  they 
belong  to  the  surgeon  and  not  to  the  dermatologist. 


THE  BUTTOCKS. 


On  the  buttocks,  from  early  infancy,  there  occurs 
a  polymorphous  dermatitis,  usually  connected  with 
intestinal   disorders    {lacquet's   disease) 

Riders  present  on  the  buttocks  a  local  furunculo- 
sis  zviih  special  characters 

Scabies  also  causes  pruriginous  lesions  in  this 
situation,  which  are  peculiar  enough  to  require 
mention 

All  the  pruriginous  diseases  may  cause  licheni- 
Hcation  in  this  region,  accompanied  or  not  by  con- 
comitant ecsematisation 

Some  toxic  eruptions  may  occur  in  this  situa- 
tion, especially  those  which  are  due  to  alkaline 
bromides 

/  shall  conclude  this  chapter  with  a  few  words 
on  the  technique  of  mercurial  injections  in  the 
treatment   of  syphilis 


Simple  p  o  1  y- 
morphous  der- 
matitis of  chil- 
dren    p.  509 

der's      furun- 
culosis P-  511 


}" 


-Scabies p.  512 


Lichenisation 


Medicamentous 
Toxidermias 


P-5I2 


P-5I2 


Technique  of  mer- 
curial   injections  p.  513 


and  on  the  intra-muscular  nodosities  w/fJc/»")  Nodosities  of  mer- 


oftett   follow   them 


curial    injections  p.  513 


SIMPLE    INFANTILE    DERMATITIS    OF   JACQUET. 


Parrot  described  as  syphilitic  an  eruption  which  Jacqiiet  and 
Sevestre  qualified  as  post-erosive  syphiloid,  and  to  which  Jacquet 
later  gave  the  name  of  simple  dermatitis  of  children. 

This  appears  to  be  a  kind  of  abortive  impetigo  of  the  region  of 
the  buttocks;  one  of  the  superficial  and  less  recognisable  lesions 
caused  in  many  cases  by  pyogenic  cocci. 

These  eruptions,  whatever  their  immediate  cause,  are  all  closely 
connected  with  digestive  disorders,  such  as  infantile  diarrhoea.  The 
first  degree  of  these  eruptions  has  been  described  in  the  anal  region 
(p.  446) .  When  they  extend  they  nearly  always  assume  the  appear- 
ance described  by  Jacquet  in  the  following  table : — 


Sio 


THE    BUTTOCKS. 


Dermatitis  of  the  ist  degree,  or  Erythema Simple  Erythema 

Erythemato-squamous Squamous   Erythema 

Pure  Vesicular  Erythema. 


Dermatitis 

of  the 
2nd  degree 


Erythemato-vesiculous 
Vesicular   Erythema  . 


Erosive  Vesicular  Erythema. 
Proliferating    vesicular    Ery- 
thema. 

(False  lenticular  syphilide 
of  Parrot.  Post  erosive 
syphiloid  o  f  Jacquet. 
Lenticular  Erythema  of 
Sevestre.  Polymorphous 
or  mixed  vesicular  ery- 
thema. 
Dermatitis  of  the  3rd  degree. 

Dermatitis   intertrigo Simple,  erosive,  ulcerative. 


Fig.  208. 


Papular    dermatitis:    post-erosive    syphiloid    (Parrot's    disease, 
Incorrectly    described    by    him    as    syphilitic). 


From  the  above  table  it  will  be  seen  that  the  lesions  vary  from 
erythema  to  ulceration,  and  that  they  occur  in  all  forms  and  degrees ; 


THE    BUTTOCKS.  511 

erythematous,  diffuse,  localised,  simple,  papular,  vesicular  and  ulcer- 
ative. It  is  necessary  to  know  that  the  earliest  degrees,  or  the  most 
simple,  and  the  earliest  forms  or  the  most  benign,  are  the  common- 
est. It  must  also  be  remembered  in  practice,  that  syphilis  should 
not  be  diagnosed  at  first  sight  in  cases  of  lesions  of  the  buttocks  in 
infants  If  syphilis  really  exists,  the  lesions  will  seldom  be  the  first 
and  never  the  only  ones. 

The  treatment  of  simple  infanttle  dermatitis  consists  first  in 
strict  local  cleanliness.  The  linen  should  be  changed  every  time  it 
is  soiled.  The  lesions  should  be  covered  with  oxide  of  zinc  paste 
(i  in  3)  containing  one  per  cent  cf  ichthyol  and  resorcine. 

The  diet  also  requires  careful  regulation,  as  it  is  usually  defective. 
Palpation  of  the  flanks  often  reveals  acute  pain  in  the  caecum  and  in 
the  ascending  and  descending  colon,  which  sometimes  necessitates 
small  doses  of  calomel. 


RIDER'S   FURUNCULOSIS. 


Rider's  furunculosis  is  caused  by  the  traumatism  of  the  saddle, 
and  is  at  first  localised  to  the  buttocks.  This  furunculosis  is  staphy- 
lococcic (p.  185),  and  the  traumatism  is  only  an  auxiliary  cause  of 
Its  localisation  and  multiplication.  The  eruption,  which  may  com- 
prise from  10  to  50  furuncles,  may  require  rest  in  bed,  especially 
as  the  friction  of  the  rough  and  infected  clothes,  and  friction  of  the 
lower  limbs  against  the  horse,  may  disseminate  the  furuncles  along 
the  inner  surface  of  the  limb;  and  if  riding  is  continued  each  fur- 
uncle undergoes  a  peripheral  necrosis,  which  constitutes  a  veritable 
ecthyma  (p.  298). 

In  spite  of  this  general  symptoms  are  absent,  excepting  lymphan- 
gitis and  the  complications  of  abscess.  Pain  is  always  present,  but 
variable. 

Treatment  consists  in  suppression  of  the  cause  and  moist  dressings 
to  remove  the  crusts ;  a  weak  carbolic  acid  spray  ( i  in  500)  is  useful 
for  this  purpose.  Each  ulceration  is  dressed  wnth  subcarbonate  of 
iron  ointment  ( i  in  40)  ;  and  each  commencing  boil  is  punctured 
with  the  galvano-cautery,  a  proceeding  which  often  causes  abor- 
tion of  the  boils,  when  done  in  time- 


512  THE    BUTTOCKS. 

SCABIES. 

The  localisation  of  scabies  to  the  buttocks  is  one  of  the  most 
frequent,  and  usually  one  of  the  most  marked.  It  forms  part  of 
the  group  of  anterior  and  posterior  lesions  situated  in  the  hypogas- 
trium,  the  genital  organs,  the  root  of  the  thighs,  the  loins  and  but- 
tocks, which  constitutes  what  Hebra  termed  the  calecon  galeux. 

On  the  buttocks  there  are  abundant  lesions  caused  by  scratching, 
with  or  without  scratch  marks  made  by  the  nails.  The  elementary 
lesions  of  scabies  are  seldom  recognisable  in  this  region,  and  must 
be  looked  for  on  the  penis,  hands,  wrists,  breasts  and  axillae.  (For 
the  treatment  of  Scabies  see  page  537) 


LICHENISATION. 

In  chronic  eczemas,  prurigos  and  divers  pruriginous  diseases 
(P  543))  the  region  of  the  buttocks  is  one  of  the  most  common 
seats  of  the  chronic  process  of  irritation  and  infiltration  known  as 
lichenisation.  I  have  already  spoken  of  these  clinical  forms  in  the 
sacral  region,  where  they  are  often  observd  (p.  506). 

Sometimes  there  are  placards  of  true  lichenification,  the  neuro- 
dermatitis of  Brocq  or  the  lichen  circumscriptus  of  Vidal.  Some- 
times a  process  of  eczematisation  is  mixed  with  it,  and  then  the  sur- 
face of  the  lichenised  patch  is  excoriated,  moist  or  more  or  less 
covered  with  yellow  crystalline  crusts,  as  fine  as  amber  dust,  adhe- 
rent to  the  irritated  epidermic  surface.  The  treatment  of  these  lesions 
seems  to  depend  more  on  the  mode  of  cutaneous  reaction  of  the 
individual  than  on  the  cause  of  the  pruriginous  dermatosis. 


TOXIC  MEDICAMENTOUS  ERUPTIONS. 

The  buttocks  are  sometimes  the  seat  of  election  of  medicamentous 
eruptions,  or  toxidermias,  caused  by  bromides,  iodides,  antipyrin, 
etc.  Whenever  a  strange  eruption  of  abnormal  type  suddenly 
appears  in  this  region,  medicamentous  eruptions  should  be  thought 
of,  and  an  enquiry  instituted.  The  only  treatment  required  is  sup- 
pression of  the  cause,  and  the  application  of  cicatrising  agents  when 
there  is  ulceration. 


THE    BUTTOCKS.  513 

TECHNIQUE  OF  MERCURIAL  INJECTIONS. 

Mercurial  injections  employed  in  the  treatment  of  syphilis  are 
usually  made  in  the  buttocks,  because  experience  shows  that  it  is 
necessary  to  make  them  deeply  in  the  muscular  tissue,  and  this 
region  fulfils  these  conditions  best.  The  technique  is  as  follows : 
The  platinum-iridium  needle,  mounted  on  an  empty  syringe,  is 
passed  through  a  flame  and  plunged  deeply  into  the  buttock  internal 
to  the  course  of  the  sciatic  nerve  behind  the  great  trochanter;  this 
is  the  only  point  it  is  necessary  to  avoid.  The  patient  should  con- 
tract the  buttocks  to  diminish  the  slight  pain  of  the  puncture. 

The  needle  being  inserted,  the  piston  of  the  syringe  is  withdrawn 
to  see  if  any  blood  comes ;  if  not,  the  empty  syringe  is  replaced  by 
the  prepared  one  and  the  injection  made.  The  needle  and  syringe 
are  removed  and  the  region  is  rubbed  with  a  pad  of  wool  soaked  in 
alcohol;  this  friction  is  intended  to  displace  the  layers  of  muscular 
tissue  and  thus  close  the  path  of  the  needle  and  prevent  escape  of 
the  injected  liquid. 

If  blood  is  withdrawn  by  the  empty  syringe,  the  needle  is  in  a 
vessel  and  may  be  thrust  in  deeper,  or  withdrawn  or  displaced.  This 
is  important,  for  injections  of  insoluble  or  oily  preparations  made 
in  an  artery  may  give  rise  to  painful  emboli  followed  by  deep 
sloughing.  This  is  a  rare  accident  which  should  be  avoided  by  the 
above  technique.  Some  surgeons  apply  collodion  to  the  orifice  of 
the  puncture ;  this  is  right  in  theory,  but  may  be  neglected  in  prac- 
tice. A  puncture  of  this  kind  only  leads  to  suppuration  when  the 
needle  or  the  injected  liquid  is  septic.  It  is,  however,  always  useful 
to  wash  the  part  with  alcohol  and  ether  before  puncture.  The 
platinum-iridium  needles  can  be  sterilised  in  the  flame  without 
softening,  and  are  for  this  reason  employed  by  preference. 

The  syringe  made  after  the  type  of  Barthelemy's  for  grey  oil  is 
preferable  to  all  others,  because  the  liquid  which  it  retains  after 
injection  being  antiseptic,  there  is  no  need  to  remove  and  clean  it 
after  each  injection.  The  syringes  for  soluble  injections,  or  for 
calomel,  with  a  capacity  of  one  cubic  centimetre,  are  boiled  for  five 
minutes  before  use. 

NODOSITIES  OF  MERCURIAL  INJECTIONS. 

In  certain  patients,  when  mercurial  preparations  are  injected  into 
the  buttocks   for  the  treatment  of  syphilis,  hard,  visible,   painful 


514  THE    BUTTOCKS. 

nodosities  are  sometimes  formed  by  chronic  inflammatory  infiltra- 
tions around  the  point  of  injection.  This  condition  occurs  chiefly 
with  insokible  preparations,  such  as  calomel  and  grey  oil,  and  when 
the  injection  is  not  made  deep  enough.  It  may,  however,  occur  in 
the  case  of  soluble  preparations,  even  when  injected  deeply.  These 
nodosities  occur  from  5  to  15  days  after  injection,  and  are  not  spon- 
taneously painful  except  during  development.  They  remain  sensi- 
tive to  pressure  for  several  weeks,  and  gradually  disappear  in  the 
course  of  a  few  months. 

The  reason  why  these  nodosities  occur  only  in  certain  subjects  is 
not  clearly  determined.  The  role  of  these  .nodosities  in  diminishing 
the  absorption  of  the  salts  injected  is  beyond  question;  they  have 
been  found,  in  necropsies  after  many  months,  in  a  cystic  condition 
containing  mercurial  salts  in  abundance.  In  cases  where  the 
nodosities  are  constant,  large,  and  painful,  it  may  be  better  to  use 
the  older  methods  of  treatment  for  syphilis,  for  the  pain  and 
deformity  are  avoided  and  possibly  the  quantity  of  mercury  absorbed 
is  better  appreciated. 

The  remains  of  these  multiple  nodosities  must  not  be  mistaken  for 
lipomata,  fibromata  or  gummata,  even  if  the  patient  denies  their 
origin. 


GENERALISED  DERMATOSES. 

There  are  eruptive  diseases  which  are  generaUsed  over  the  sur- 
face of  the  whole  body,  or  the  greater  part  of  it;  for  instance,  the 
exanthematous  fevers. 

On  the  other  hand,  there  are  dermatoses  which,  without  being 
generahsed  on  the  whole  cutaneous  surface,  have  no  absolutely 
elective  localisation,  and  may  occur  in  any  part  of  the  body ;  epithe- 
lioma, for  example.  On  the  other  hand,  there  are  some  which  have 
elective  localisations,  but  may  be  also  generalised  over  the  whole 
body,  and  therefore  require  a  general  description ;  scabies  for 
instance. 

These  diseases  are  very  numerous,  and  require  classification.  This 
classification  should  be  simple  enough  for  a  student,  without  pre- 
vious dermatological  knowledge,  to  be  able  in  this  part  of  the  book, 
as  in  the  others,  to  easily  find  the  dermatological  type  put  before 
him. 

Plenk  and  IVillan  (XVIII-XIX  centuries)  have  given  us  the 
method.  They  observed  that  cutaneous  eruptions  were  nearly  all 
constituted  by  the  infinite  repetition  of  the  same  small  lesion,  which 
they  called  the  elementary  lesion.  But  the  elementary  lesions  are 
not  of  very  many  forms  and  it  is  thus  easy  to  retain  their  definition. 
They  furnish  us  with  a  very  simple  classification  which  any  student 
may  easily  follow. 

There  are  cutaneous  diseases  characterised  ex- 
clusively by  the  dry  squamc;  by  horny  exfolia- 
tion zvithout  redness  or  exudation  around  it.  These 
constitute  the  first  group  of  simple  squamous  der- 
matoses   

There  are  other  dermatoses,  of  which  the  pri- 
mary element  is  a  flat  pruriginous  elevation,  iden- 
tical with  that  caused  by  a  nettle  sting.  These  form 
the    Urticarial   group 

Before  considering  the  essential  dermatoses  in 
li'hich  pruritus  is  a  dominant  factor,  I  shall  sketch 
the  parasitic  verminous  diseases  zvhich  are  easily 
confounded    with    prurigos 

There  exists  a  category  of  cutaneous  nosograph- 
ical  types  which  arc  characterised  by  pruritus;  the 
pruriginous  papule,  a  small,  dry,  raised,  Hat  lesion, 
isolated  or  grouped  in  thick  quadrillatcd  placards. 
Along  ivith  the  prurigos,  xve  shall  give  a  review 
of  all  affections  with  papular  or  papuloid  lesions 


Squamous 

d  e  r- 

matoses 

P- 

517 

Urticarial 

derma- 

toses   .    . 

P- 

531 

Verminous 

derma- 

toses  .    . 

P- 

537 

Papular    and    lich- 
enoid   dermatoses  p.  543 


516 


GENF.RALISED    DERMATOSES. 


Vesicular  and  exu- 
dative derma- 
toses   p.  559 


toses 


p.S68 


There    is    also    a    class    of   cutaneous   affections 
characterised  by  the  vesicle,  an  element  constituted 
by  a  minute  collection  of  clear  fluid,  slightly  rais- 
ing  the   superiicial   epidermis.     When   a   vesicular 
dermatosis  is  excoriated  it  becomes  exudative  .    .. 
There  is  another  class  of  dermatoses  character-^ 
iscd  by  the  pustule;  and  this  element  is  caused  ap-    Pustular  and  ulcer 
parently  by  a  vesicle  zuhich,  instead  of  clear  Utiid,  I      ative      derma- 
contains  pus.      7 he   open   pustular   elements   form 

more  or  less  superficial  ulcerations J 

Apart  from  the  preceding  dermatoses  there  are' 
others   zuhich   have   the   common   characteristic   of 
redness  of  the  skin,  or  erythema.     This  erythema 
may  be  formed  of  small  patches  or  macules  zuhich 
disappear  by  pressure.     For  instance,  measles  and 

the-  rubeoliform  eruptions 

The  erythema  may  be  scarlet  and  diffuse  on  large^  Scarlatina         and 
areas.     This  condition  is  acute  and  of  the  type  of  I     scarlatiniform 

scarlatina   and   scarlatiniform    eruptions j      eruptions  ...  p.  585 

Or  it  may  constitute  erythrodermia  with  exten-1 
sive  scaly  desquamation,  of  the  type  of  an  exten- 
sive, apyretic  and  chronic  erysipelas I 

Lastly,  there  are  eruptions  constituted  by  intra-1. 
cutaneous  effusions  of  blood  in  macules  or  in  con- 
tused patches  zuhich  do  not  disappear  zuith  pressure  j 


Measles  and  rube- 
oliform e  r  u  p- 
tions p.  578 


Erysipelas        and 
erythrodermia     .  p.  580 

Purpura    and    pur- 
puric eruptions  .  p.  593 


/  shall  devote  a   chapter   to   the  description    of\  .     .. 

variola,  varioloid  and  varicella J       ^       '  ^'  ^^ 


Also  to  eruptions  of  zvhich  the  elementary  lesion 
is  a  bulla  or  large  vesicle,  consecutive  to  pemphi- 
goid eruptions 

There  is  also  the  scries  of  dyschromias,  melano- 
dermia  and  vitiligo;  and  sclerous  changes  of  the 

skin  called  sclerodermia  and  morphoca 

Also  the  series  of  tumours  of  the  skin,  from  the 
smallest,  such  as  milium  and  mulluscum  contagio- 
sum,  up   to   the   largest  tumours   of  mycosis   fun- 

goides  and  sarcoma 

Lastly,  there  are  severe  general  diseases,  the' 
duration  of  zuhich  is  counted  by  years,  of  zi'hich 
the  cutaneous  manifestations  differ  less  in  their 
situation  on  the  body  than  by  their  date  in  the  evo- 
lution of  the  disease;  leprosy  and  syphilis  for  ex- 
ample    


Bullous  and  pem- 
phigoid e  r  u  p- 
tions p.  602 

Dyschromia     Scler- 
odermia .    .    .    .  p.  611 


Tumours 
skin     . 


of    the 


p.  618 


Chronic    infectious 
dermatoses    ..     .  p.  644 


THE   SQUAME. 
STEATOID  AND  SUPER-SEBORRHOEIC  PSORIASIS. 


Elementary  Lesion:  The  Squame. 

A  certain  number  of  general  squamous  diseases,  differing  con- 
siderably in  form  and  in  evolution,  have  the  squame  as  a  common, 
primordial,  objective  character. 

In    Ichthyosis,    or   generalised    congenital   hyper-' 
keratosis,   the  generalisation    {except  in   the   folds 
of  flexion),  and   the  congenital  nature   require   to 
be  considered 

There  are  also  pronounced  or  hardly  visible  de- 
squamations, which  folloiv  a  great  number  of  erup- 


Ichthyosis 


p-sn 


Desquamation      of 


..       ,                  J   .          •  pyrexia  .   .   . 

ttve  fevers,  and  pyrexias I      ^-^ 

There  is  also  the  desquamation  of  the  bed-riddc;0.  Desquamation 


p.Si8 


of 


the  bed-ridden  .  p.  519 


(pityriasis  tabescentium) J 

The  name  of  pityriasis  was  given  by  IVillan  to 
all  the  morbid  types  which  are  essentially  char- 
acterised by  the  squame.  There  are  Ave  derma- 
tological    types    under    this   name 

The  first  is  pityriasis  capitis,  which  may  occur 
on  the  front  of  the  thorax,  and  is  in  rare  cases 
generalised 

The  second  is  pityriasis  versicolor,  a  mycosis 
of  the  horny  epidermis;  disposed  in  geographical, 
brown  patches;  generally  situated  on  the  thoracic 
region,  but  sometimes  extending  to  the  whole  trunk, 
and  even  the  whole  body,  except  the  extremities 

Pityriasis  rosea  was,  up   to   the  time  of  Giber t,~ 
confounded  zvith  syphilitic  roseola.    It  is  a  gener- 
alised eruption  of  pink  spots,  ivhich  become  bistre 
coloured  and  edged  zi'ith  a  squamous  fringe   .    .    . 

The   fourth  pityriasis   is   the  pityri<isis   rubra   of\  Pityriasis  rubra  of 
Hebra,  an  exfoliating  erythrodermia   (p.       )    .    .    ,J       Hebra P- 52 

The  fifth  is  an  affection  closely  related  to  /)J0-1  Pityriasis     rubra 


-  Pityriasis p.  519 


Simple    and     stea- 
toid    pityriasis   .  p.  519 


Pityriasis     v  e  r  s  i- 
color p.  520 


Pityriasis  rosea  of 
Gibert P-  S21 


riasis,  and  will  be  studied  after  it 


pilaris 


Drv  eczema  ma\  occur  without  a  preceding  stage\  _^ 
r     '     1  .-            '  fDry  eczema 

of  exudation J       •' 

I  shall  next  study  psoriasis  as  a  whole,  the  chief 
characters  and  principal  localisations  of  which  zi.'e  [-Psoriasis 
have  alreadv  considered 


•    PS22 
.    P-522 

-  P-  525 


Si§  THE   SQUAME. 

And  the  pityriasis  rubra  pilaris  of  Devergie- 
Besnier,  a  rarer  disease  than  psoriasis,  but  with 
very  similar  characters 

/  shall  conclude  xnnth  a  few  words  on  the  rare 
eruptions  called  parakeratosis  variegata  and  para- 
psoriasis   ". 


Pityriasis     rubra 
pilaris     ....  p.  528 

Parapsoriasis  .  .  .  p.  530 


ICHTHYOSIS. 

Ichthyosis  is  easily  recognised  by  two  characters:  the  hyperkera- 
tosis which  constitutes  it  is  generahsed,  and  it  exists  from  the  earliest 
infancy. 

It  may  occur  in  all  degrees,  from  that  which  renders  the  skin 
slightly  floury,  dry  and  grey,  to  that  which  forms  thick,  coarse, 
black,  crackled,  adherent  patches,  covering  the  body  (ichthyosis 
hystrix).  The  disease  is  sometimes  consanguineous  and  hereditary, 
but  not  always.  It  increases  a  little  with  age,  from  6  to  15  years. 
It  avoids  the  folds  of  flexion,  and  is  always  more  marked  on  the 
extensor  surfaces  of  the  limbs.  It  has  been  studied  on  the  limbs 
(p.  284)  and  scalp  (p.  179),  and  is  only  mentioned  here  to  differ- 
entiate it  from  the  different  squamous  diseases  which  may  become 
generalised.    The  treatment  of  ichthyosis  is  purely  palliative. 

Xerodermic  skins  have  necessarily  a  special  hygiene  which  in- 
cludes frequent  alkaline  baths  to  clean  the  hard  and  adherent  homy 
layers;  applications  of  glycerole  of  starch  with  resorcine,  or  oxide 
of  zinc  cream  with  i  per  cent  of  salicylic  acid. 


DESQUAMATION  OF  PYREXIAS. 

Every  pyrexia,  infectious  disease  or  eruptive  fever,  and  every 
febrile  disease  with  cutaneous  phenomena,  may  terminate  by  a  des- 
quamative stage,  which  is  very  marked  in  scarlatina,  less  marked 
in  measles,  etc.,  but  may  occur  in  all.  In  the  case  of  a  desquamation 
with  large  squames,  scarlatina  (p.  585)  and  recurrent  scarlatiniform 
erythema  (p,  587)  should  be  thought  of,  for  there  are  some  forms 
of  unrecognised  scarlatina.  All  corroborative  evidence  bearing  on 
the  retrospective  diagnosis  should  be  carefully  investigated.  In 
themselves  these  desquamations  are  of  little  importance  and  dis- 
appear spontaneously ;  but  after  scarlatina  and   variola  they  may 


THE    SQUAME.  gi^ 

be  the  agents  of  contagion ;  hence  the  practice  of  applying  vaseHne 
to  the  whole  surface  of  the  body,  during  convalescence.  The  fol- 
lowing cream  is  also  useful  for  this  purpose : — 

Oxide   of  zinc 2  parts 

Oil    of    Almonds 

Vaseline ' 

Lanoline 


-    aa  3  parts 


DESQUAMATION  OF  THE  BED-RIDDEN.     PITYRIASIS 
TABESCENTIUM. 

This  is  especially  marked  on  the  flanks  and  limbs,  and  resembles  a 
transient  ichthyosis.  Like  ichthyosis,  it  covers  the  skin  with  a  thin, 
grey,  crackled,  horny  cortex,  partly  adherent,  and  partly  dehiscent. 
The  persistence  of  the  desquamating  horny  layer  is  due  to  immobility 
and  to  the  absence  of  cleanliness.  Treatment  consists  in  baths  and 
soaping. 

PITYRIASIS. 

The  word  pityriasis  (7rn-/u,/30T,  bran)  has  been  revived  in 
dermatological  parlance  by  one  of  the  principal  founders  of  modern 
dermatology,  R.  IVillan,  who  considered  the  squame  as  the  only 
characteristic  of  pityriasis.  The  name  pityriasis  is  given  to  five 
essentially  different  morbid  types,  the  clinical  characters  of  which 
1  shall  brieflv  describe. 


PITYRIASIS  SIMPLEX  VEL  CAPITIS. 

Pityriasis  capitis,  forming  dry  pellicles  on  the  scalp,  is  a  chronic 
disease  characterised  by  the  dehiscent  squame,  without  inflammatory 
reaction  of  any  kind  (p.  207). 

In  many  cases  this  is  transformed  into  pityriasis  with  steatoid 
squames,  greasy  to  the  touch,  under  which  the  epidermis  is  rather 
redder  than  normal  (p.  208).  These  two  forms  of  simple  and  stea- 
toid pityriasis  are  primarily  situated  on  the  scalp,  bvit  have  a  second 
localisation  on  the  anterior  and  posterior  medio-thoracic  regions. 


520 


THE   SQUAME. 


from  which  they  may,  for  a  time,  extend  and  multiply  On  the  whole 
body.  This  is  the  parasitic  eczema  of  Besnier.  It  may  extend 
from  the  scalp  to  the  face. 


Fig.  203.     Parasitic    Eczema    of    Besnier    (Pityriasis    Simplex).      ej,    young    elements; 
cc,   exfoliative  circles.      (Besnier's  patient.     St.    Louis   Hosp.   Museum,    No.    873.) 

These  generalisations  are  very  incomplete  and  temporary,  and 
hardly  require  mention  in  an  elementary  book.  This  eruption  has 
the  exact  characters  figured  on  p.  474  and  described  on  p.  120. 


PITYRIASIS    VERSICOLOR. 

Pityriasis  versicolor  is  constituted  by  patches  of  different  sizes, 
with  geographical   outlines,  and  of  a  brown  colour,   commencing 


THE   SQUAME.  521 

nearly  always  on  the  anterior  or  posterior  thoracic  regions  and 
generally  limited  to  them.  For  this  reason  this  disease  has  been 
described  on  page  474.  But  in  some  cases  this  chronic  dermatomy- 
cosis  may  invade  nearly  the  whole  of  the  trunk,  as  shown  in  Fig. 
194;  but  it  rarely  attains  this  degree  of  extension.  It  may  be  con- 
founded with  a  dyschromia,  a  melanodermia,  etc.  To  prevent  this 
error  it  is  sufficient  to  rub  the  patches  with  rough  lint,  which  removes 
the  greyish  brown  pityriasis  layer. 

PITYRIASIS  ROSEA. 

The  pityriasis  rosea  of  Giber t  is  a  generalised  dermatosis  which 
has  no  regional  election  and  extends  to  nearly  the  whole  of  the 
body ;  so  that  it  has  not  yet  been  described  in  this  book. 

It  arises  as  a  single  placard ;  pityroid,  irregularly  rounded  or  oval, 
with  a  red  and  very  trichophytoid  border  (Brocq).  This  patch  may 
be  situated  on  the  trunk,  shoulders,  arms,  chest  or  flanks.  It 
remains  solitary  for  2  or  3  weeks,  or  more.  Then,  in  a  few  days, 
an  erythematous  and  pityroid  eruption  develops  on  the  whole  body, 
composed  of  small  pink  macular  elements  which  enlarge  and  assume 
a  special  appearance.  The  centre  is  bistre  coloured  and  the  super- 
ficial horny  epidermis  is  finely  wrinkled,  shot  and  iridescent.  The 
periphery  of  the  patches  is  a  rose-lilac  tint,  finely  desquamative  and 
bordered  with  a  fringe  of  fine  squames.  When  examined  with  a 
strong  lens  the  peripheral  border  is  seen  to  be  vesicular,  as  is  shown 
by  its  histology. 

This  eruption  covers  the  entire  body  with  a  kind  of  roseola  which, 
before  the  time  of  Gilbert,  was  too  often  mistaken  for  syphilitic 
roseola;  this,  however,  is  never  desquamating  nor  pruriginous.  It 
increases  during  8  or  15  days;  remains  stationary  for  a  month,  and 
gradually  fades.  Its  distinctive  characters  are:  the  primary  large, 
trichophytoid  patch ;  the  uniform  eruption  on  the  body,  formed  of 
hundreds  of  patches,  and  which  avoids  the  head  and  the  extremi- 
ties ;  the  pruriginous,  pseudo-exanthematous,  non-febrile  nature  of 
the  eruption ;  and  the  rose-lilac  patches,  iridescent  and  bistre  in  the 
centre  and  desquamating  at  the  periphery. 

Pityriasis  rosea  apparently  never  recurs.  When  incorrectly 
treated  the  patches  may  become  eczematised  and  unrecognisable. 
When  properly  treated  by  anodyne  ointments  it  disappears  more 
quickly  without  complications  and  leaves  no  trace. 


522  THE    SQUAME. 

The  great  error  which  pityriasis  rosea  may  cause  results  from  its 
resemblance  to  syphilitic  roseola,  to  the  unpractised  eye.  But  there 
is  no  sign  or  doubtful  induration  of  chancre;  no  indicator  gland 
and  no  polyadenitis.  Lastly,  it  does  not  leave  behind  it  any  mark 
which  could  be  mistaken  for  the  other  lesions  of  secondary  syphilis. 


PITYRIASIS   RUBRA. 

This  name  is  only  given  to  two  morbid  types,  one  of  which  has 
been  studied  with  psoriasis,  with  which  it  has  many  affinities.  This 
is  characterised  by  follicular  acuminated,  hyperkeratosis  of  the  back 
of  the  fingers  and  hands,  giving  the  skin  the  appearance  of  a  file. 
In  France  it  is  called  pityriasis  rubra  pilaris,  the  disease  of  Devergie- 
Besnicr. 

The  second  is  pityriasis  rubra  of  Hcbra,  which  is  much  less  char- 
acterised by  lamellar  exfoliation  of  the  epidermis  than  by  intense 
redness  of  the  skin  of  the  whole  body.  It  is  now  classed  among  the 
erythrodermias   (p.  590). 

DRY    ECZEMA. 

An  eczema  may  be  dry  in  the  course  of  the  final  desquamative 
stage  following  exudation,  or  it  may  be  dry  from  the  first.  It  is 
the  latter  form  which  concerns  us  here,  the  other  being  only  a  phase 
in  acute  eczema  described  elsewhere  (p.  560). 

Dry  eczema  is  eczema  rubrurn,  also  termed  eczema  of  arthritics, 
or  gouty  eczema.  It  may  occur  in  any  situation,  but  has  a  predilec- 
tion for  the  face,  around  the  eyes,  the  back  of  the  hands,  the  fore- 
arms and  legs.  It  is  usually  very  localised,  but  may  occur  in  exten- 
sive areas. 

In  the  region  of  this  eczema  the  skin  is  red,  infiltrated,  thickened, 
hot  and  covered  with  the  debris  of  the  desquamating  horny  epider- 
mis, which  resembles  pieces  of  cigarette  paper  stuck  to  the  skin.  It 
is  very  pruriginous,  and  after  attacks  of  pruritus,  may  give  rise  to 
an  infinitesimal  exudation,  by  pores  which  are  only  visible  with  a 
lens. 

This  form  of  eczema,  the  cause  of  which  is  unknown  like  that 
of  eczema  in  general,  is  extremely  chronic.  It  is  intolerant  to  active 
medicaments,  and  anodyne  applications  have  no  eflfect  on  it. 


The  squame. 


5^5 


Wet  dressing-s  with  simple  boiled  water,  or  decoction  of  elder 
flowers,  applied  during  the  night,  give  rise  to  an  apparent  cure  when 
they  are  removed,  but  in  a  few  hours  all  the  objective  and  painful 


Fig.  20-4.     Crackled  Eczema.     (Fournler's  patient.     St.  Louis  Hoap.  Museum,   No.  453.) 


symptoms  return.     However,  by  alternating  these  with  zinc  oint- 
ment a  result  may  finally  be  arrived  at.     The  application  of  super- 


5^4  THE   SQUAME. 

heated  air  appears  to  have  a  beneficial  eflfect  on  these  forms  of 


Vig,  205.     Psoriasis    in   nummular   and   polycycllc   placards. 
(Jeanselme's   patient.      Photo   by   NoirS.) 

eczema,  but  further  experience  is  required.     Internal  treatment  is 


THE    SQUAME.  525 

unknown.  Strict  regulation  of  diet  with  abstention  from  pork, 
salt  food,  spices,  wine  and  spirits,  fish,  shell-fish,  cauliflowers,  cab- 
bages, tomatoes,  etc.,  is  often  recommended,  although  in  many  cases 
it  is  difficult  to  decide  which  of  these  ailments  has  a  bad  effect  on 
the  disease.  It  is  better  to  say  that  all  things  which  are  badly 
digested  are  bad  for  eczematous  subjects.  In  my  opinion  the  physi- 
cian should  study  the  patient  attentively,  analyse  the  urine,  and 
treat  the  stomach  and  intestine  for  any  functional  derangement 
which  may  be  present ;  but  without  any  preconceived  idea,  without 
system  and  without  a  single  formula  common  to  all  cases,  for  it  will 
be  certainly  false.  The  little  we  know  of  the  true  nature  of  eczemas, 
of  their  mechanism  and  etiology,  would  astonish  any  physician  who 
was  not  a  dermatologist. 

PSORIASIS. 

Psoriasis,  one  of  the  most  important  of  the  dermatoses,  is  a  dis- 
ease of  unknown  external  or  internal  cause,  characterised  by  a  more 
or  less  marked  eruption  of  round,  red  patches,  covered  by  a  dry, 
thick,  friable,  adherent  squame.  It  is  a  chronic,  paroxysmal,  recur- 
rent disease,  and  in  a  few  cases  is  accompanied  by  chronic  progres- 
sive arthropathies. 

Psoriasis  seldom  commences  before  the  age  of  10  years,  but  may 
occur  at  any  age  up  to  40,  or  even  later.  Nothing  announces  it  but 
the  appearance  of  a  primary  characteristic  element,  to  which  all  the 
others  are  similar.  The  mature  lesion  of  psoriasis  varies  in  size 
from  a  threepenny  to  a  five  shilling  piece  or  more,  and  is  covered 
with  a  hard,  friable  squame,  which  may  be  broken  into  thin,  soft, 
micaceous  scales.  The  squame,  when  removed  in  a  single  piece, 
exposes  a  red  skin  covered  with  blood  points.  Under  the  squamous 
crust  the  psoriasic  patch  is  red;  the  skin  is  thickened,  hard  and 
almost  painless,  but  deeply  infiltrated,  especially  in  old  lesions. 

Psoriasis  generally  begins  by  similar  patches  on  the  knees  and 
elbows,  where  they  remain  indefinitely,  coalescing  in  polycyclic 
placards,  or  remaining  distinct.  After  a  time  patches  of  different 
sizes  appear  on  the  whole  surface  of  the  body  and  the  disease 
becomes  generalised. 

There  are  benign  types  of  psoriasis,  characterised  by  few  patches 
and  rare  outbreaks;  and  severe  types,  characterised  by  innumerable 


526 


THE   SQUAME. 


patches  and  sub-involutive  outbreaks.  In  the  latter  case  the  patches 
coalesce  and  the  squames  become  united.  In  this  way  placards  are 
formed  which  may,  in  a  few  years,  cover  greater  surfaces  of  skin 
than  the  areas  which  are  free  from  the  disease. 

Normal  psoriasis  has  an  evident  predilection  for  the  elbows  and 


Fig.  206.     Psorlasic   lesions,    occurring  on  prickly   heat. 
(Jeanselme's   patient.      Photo   by    Noir§. ) 


knees,  but  this  rule  is  subject  to  exceptions  which  form  inversions 
of  the  normal  type.  In  these  cases  the  psoriasis  has  pseudo-sebor- 
rhoeic  or  steatoid  crusts,  often  arsing  on  seborrhoeic  skins. 
Psoriasis  shows  very  numerous  objective  varieties — annular  poly- 
cyclic,  guttate,  in  placards,  etc. ;  and  varieties  in  evolution — 
localisation  to  the  scalp,  elbows  and  knees,  nails,  nerve  trunks, 
traumatised  regions,  after  prickly  heat  (Jcansclnic)  and  arthro- 
pathic  psoriasis.     The  last   form  is  characterised  by  progressive 


THE    SQUAME. 


527 


arthropathies  commencing  in  the  extremities  and  ending  in  the  cHni- 
cal  picture  of  arthritis  deformans,  with  complete  or  incomplete  anky- 
losis of  some  or  nearly  all  of  the  joints.  This  disease  is  very  easy 
to  improve,  but  difficult  to  cure,  and  its  recurrence  after  apparent 
cure  is  common. 

The  etiology  of  psoriasis  is  quite  unknown,  and  opinions  on  the 
subject  are  purely  hypothetical.  The  morbid  anatomy  of  the  lesion 
covered  by  the  squamous  crust  shows  it  to  be  one  of  the  most  char- 
acteristic and  most  specific  of  the  cutaneous  diseases,  without  affirm- 
ing its  endogenous  or  exogenous  nature. 

The  squame  of  psoriasis  was  formerly  considered  to  be  formed 
exclusively  by  a  simple  process  of  hyperkeratosis.  It  is  now  known 
that  the  horny  layers  enclose  minute  collections  of  leucocytes  effused 
successively  on  the  surface  of  the  epidermis  by  exocytosis.  These 
collections  of  leucocytes,  encapsuled  by  the  horny  strata,  constitute 
essentially  the  psoriasic  squamous  crust. 

The  treatment  of  psoriasis  by  eukeratosic  and  keratolytic  agents 
is  one  of  the  best  established  and  most  methodical  procedures  in 
dermatology.  The  most  useful  drugs  are  the  tars,  especially  oil  of 
cade  (juniper),  ichthyol,  salicylic  acid,  pyrogallic  acid  and  chrysaro- 
bin.  These  may  be  used  in  the  form  of  ointment,  lotion  or  trau- 
maticin.  The  rule  is  to  proportion  the  doses  to  the  limit  of  resist- 
ance of  the  skin  of  the  patient,  by  graduated  formulas.  Compound 
preparations  generally  give  the  best  results. 


(l)  Ichthyol  .  .  .  , 
Resorcine  .  . 
Oil  of  Birch 
Oil  of  Cade 
Vaseline  .  .  . 
Lanoline   .    . 


aa     I  gramme    V 

2  grammes 
13  grammes 

aa  15  grammes  I 


aa  gr.  32 

5vii 
3j 

aa  5j 


(2)  Ichthyol 

Resorcine  .  .  .  . 
Turpeth  mineral 
Pyrogallic  acid  . 
Oil  of  birch  .  .  . 
Oil  of  cade  .  .  .  . 
Lanoline  .  .  .  , 
Vaseline     .     .   .    , 


aa     I  gramme 


2  grammes 
13  grammes 


aa  15  grammes 


aa  gr.  32 

3j  ^ 
3vii 

aa  5J 


(3)  To  the  second  formula  may  be  added  30  to  50  centigrammes 
(gr.  10  to  16)  of  chrysophanic  acid  or  i  gramme  (gr.  32)  of  chry- 


528  THE    SQUAME. 

sarobin ;  but  these  are  very  active  and  irritating  preparations  which 
require  careful  supervision.  Pyrogallic  acid  may  cause  albuminuria 
and  chrysophanic  acid  a  special  erythema. 

If  the  odour  of  the  oil  of  cade  is  objectionable  the  following  may 
be  substituted: — 

Chrysarobin I  gramme  gr.  i6 

Oxide   of  zinc 6  grammes  5i  ss 

Turpeth    mineral I  gramme  gr.  32 

Vaseline 30  grammes  5j 

or  solution  of  chrysarobin  in  traumaticin,  or  chloroform  (10  per 
cent),  applied  to  each  patch  with  a  brush  and  covered  with  simple 
traumaticin  {Besnier). 

PITYRIASIS    RUBRA    PILARIS. 

Pityriasis  rubra  pilaris,  which  is  considered  by  all  authors  as  a 
disease  very  analogous  to  psoriasis,  but  much  rarer,  has  been 
described  by  Dcvergie  and  Besnier.  This  affection  usually  com- 
mences in  adolescence,  and  is  more  common  in  men;  it  is  neither 
consanguineous  nor  hereditary.  Like  psoriasis,  it  may  be  localised 
or  generalised,  but  has  a  greater  tendency  to  generalisation.  The 
causes  are  unknown,  either  of  the  successive  crops  or  of  the  spon- 
taneous resolution. 

It  begins  on  the  back  of  the  hands  and  fingers  by  hyperkeratotic 
follicular  lesions  of  a  conical  form,  described  on  page  369.  These 
lesions  may  become  generalised  in  this  form,  so  that  the  patient's 
skin  is  as  rough  as  a  file.  A  marked  hypersemia  is  nearly  always 
added  to  these  lesions  with  slight  infiltration  of  the  skin,  more  appa- 
rent on  the  face  and  the  folds  of  flexion,  and  which  may  extend  con- 
siderably beyond  the  regions  affected  with  the  horny  peripilary 
cones.  Also,  sheets  of  hyperkeratosis  may  occur  on  the  face,  scalp 
and  folds  of  flexion,  constituting  a  white,  chalky,  lamellar  exfolia- 
tion on  the  face;  rather  softer  and  less  dry  on  the  scalp,  and  occa- 
sionally leading  to  temporary  loss  of  hair.  The  nails  are  also 
striated  transversely.  Lastly,  in  typical  cases,  pityriasis  rubra 
pilaris  appears  like  an  acute  psoriasis,  in  squamous  patches,  but 
rather  more  acute,  more  violet  than  red.  and  less  infiltrated  than  in 
psoriasis.  But  the  differential  symptom  between  the  two  diseases  is 
furnished  by  the  skin  of  the  back  of  the  fingers  and  its  horny  fol- 
licular cones,  which  are  never  absent. 


THE    SQUAAIE.  529 

The  evolution  resembles  psoriasis  in  its  length  of  duration,  its 
recurrences,  its  sudden  outbreaks  and  periods  of  quiescence  and  in 
its  resistance  to  treatment.  The  treatment  is  identical  with  that  of 
psoriasis,  and  the  results  are  analogous  (p.  527).  In  acute  out- 
breaks of  pityriasis  rubra  pilaris  the  therapeutic  results  are  incom- 
parably better  than  in  pityriasis.  As  in  psoriasis  the  general  health 
is  not  affected.  The  resemblance  of  the  nomenclature  might  con- 
found pityriasis  rubra  pilaris  with  pityriasis  rubra  of  Hcbra;  but 
these  diseases  have  nothing  in  common ;  the  pityriasis  rubra  of 
Hebra  is  a  malignant,  exfoliating  erythrodermia  (p.  590)  of  grave 
prognosis.  Pityriasis  rubra  pilaris  is  often  designated  lichen  ruber 
acnmiiiafus.     (Kaposi-A'cisser). 

PARAKERATOSIS    VARIEGATA. 

Unna  has  described  under  the  name  of  parakeratosis  variegata, 
and  Brocq  under  the  name  of  parapsoriasis  in  sheets,  an  affection 
of  which  little  is  known  except  its  external  characters. 

It  is  a  pityroid  eruption  with  extensive  superficial  desquamation, 
generally  occupying  the  upper  part  of  the  trunk  and  the  arms ;  but 
it  may  cover  nearly  the  whole  body.  The  desquamation  is  not  very 
marked  and  the  squames  are  adherent  to  the  skin,  giving  it  an  iri- 
descent appearance.  This  feature,  together  with  the  extreme  chron- 
icity  of  the  eruption  and  its  resistance  to  the  usual  keratolytic  agents, 
form  the  best  known  characters  of  this  affection,  the  exact  nature 
of  which,  with  its  cause  and  treatment,  are  unknown. 

Chrysarobin  (i  in  40),  pyrogallic  acid  (4  per  cent),  and  the  most 
active  keratolytic  agents  may  be  tried,  as  in  cases  of  rebellious 
psoriasis. 

PARAPSORIASIS    IN    PATCHES    AND    DROPS. 

Brocq  connects  with  the  preceding  type,  under  the  name  of  para- 
psoriasis in  patches  and  drops,  discrete  pityroid  and  psoriasiform 
eruptions,  formed  of  a  few  small  elements,  differing  from  psoriasis 
in  the  absence  of  any  tendency  to  generalisation,  the  resistance  to 
medicaments,  the  long  duration  in  the  same  place,  and  by  the  fact 
that  scratching  the  squames  easily  provokes  a  tint  of  ecchymosis 
under  the  lesion.    This  affection  is  at  least  as  rare  as  the  preceding 

34 


530  THE    SQUAME. 

one;  and  the  cause,  progress  and  treatment  have  not  yet  been  deter- 

The  most  active  reducing  agents  may  be  tried,  such  as  chrysarobin 
and  pyrogaUic  acid,  applied  in  strong  oil  of  cade  ointments,  or  under 
traumaticin,  as  in  rebellious  psoriasis. 


URTICARIA. 


Elementarv  Lesion:  The  Nettle-rash  Papule. 


Nettle-sting 


Dermographism  .  p.  533 


ab     in- 


Urticarias    arc    special    erythemas    cliaracterised' 
by   elevations,  identical  zcith   those  caused  by   the 
nettle  sting.     JVe  shall  first  study  the  nettle  sting 
itself 

In   contrast   zi'ith    this   artificial   urticaria   is   the 
chronic    condition    knozvn    as    dermographism,    in 
Zi'hich   the  skin  is  in  a  condition   to  present  trau-  . 
matic,    but    not   spontaneous   urticaria J 

We  shall  next  consider  the  urticarias  of  m/o.r/-\ Urticaria 
cation;  some  due  to  alimentary  intoxciafions   .    .    .J     gestis   .  .    .    . 

.         .  ~l  Medicamentous 

.    .    .   others  to  medicamentous  intoxications  .    .  L         ,• 

J      urticaria      .    . 

.  .  .  Others  are  due  to  the  penetration  of  the 
fiuid  of  hydatid  cysts  in  the  economy.  These  are 
only  mentioned  by  the  zvay 

After  studying  the  urticarias  zcith  definite  causes, 
Ti'e  shall  consider  the  essential  urticarias  in  zvhich 
no  precise  or  suMcient  cause  has  been  demon- 
strafed.  First  the  acute  and  chronic  urticarias  of 
children 

JVe  shall  next  deal  zcith  the  essential  urticarias 
of  adults;  urticarial  purpura;  tuberous,  giant  and 
gangrenous  urticarias;  leaving  the  study  of  pig- 
mentary urticaria,  zvhich  is  not  a  true  urticaria, 
to  the  chapter  on  papular  diseases  (p.  558)    .     .     . 


P-532 


P-534 


P-53S 


Essential    urticar- 
ias of  children  .  p.  535 


Urticarias   of 
adults      ....  p.  537 


THE  NETTLE  STING.     THE  NETTLE-RASH  LESION. 


Everyone  knows  the  nettle-sting,  forming  a  flat,  oval,  white  or 
pink  elevation,  generally  centred  by  a  depressed  spot,  the  puncture 
of  the  urtica  nrens.  This  lesion  is  important  in  dermatology, 
because  it  is  the  prototype  of  a  series  of  elements  which  are 
analogous,  although  of  different  origin. 

In  this  case  are  to  be  noted :  ( i )  the  external  traumatism  which 
causes  it;  (2)  the  intense  pruritus;  (3)  the  action  of  pruritus  on 
its  formation,  for  even  when  it  has  disappeared  the  pruritus  causes 
it   to   reappear ;    (4)    the    lesion    consisting   in    an    acute   localised 


532  URTICARIA. 

oedema,  this  phenomenon  assumes  the  active  participation  of  the 
vaso-motors,  either  l^y  reflex  action  through  sensory  nerves,  or  by 
direct  intoxication  of  the  vaso- motor  nerves  at  the  same  time  as  the 
sensory. 

The  rapid  appearance  of  the  nettle-rash  is  singular,  and  its  rapid- 
ity of  onset  and  disappearance  form  the  chief  characteristics  of  the 
lesion.  Xettle-rash,  in  spite  of  numerous  investigations,  still  offers 
material  for  numerous  studies  in  experimental  dermatology,  which 
may  throw  some  light  on  the  study  of  urticaria. 

DERMOGRAPHISM. 

In  contrast  with  the  nettle-sting,  which  causes  a  rash  even  on 
skins  which  have  no  tendency  to  show  spontaneous  urticaria,  rjiust 
be  placed  the  latent  urticarial  reaction  known  as  dermographism. 


Flgr.  207.     Traumatic    StiKmatisation.      The    "ilev.l  s    iiaiid' : 
Sigillum   diaboli.      (Barthelemy's   patient.) 

Certain  skins  present  an  urticarial  reaction  to  every  traumatism 
corresponding  exactly  to  the  surface  where  the  traumatism  is  pro- 


URTICARIA. 


533 


duced.  A  scratch,  the  friction  of  clothes,  even  a  design  made  with 
a  blunt  point,  provoke  urticarial  and  pruriginous  elevations  of  all 
the  lines  traced  on  the  skin.  This  propensity  is  durable,  and  the 
same  subject  shows  it  in  different  degrees  during  several  years. 

The  subject  is  usually  a  neurotic  or  hysterical  woman,  but  cases 
may  occur  in  women  who  have  no  other  sign  of  neurotic  tendency. 
The  subjects  of  dermographism  are  not  usually  subject  to  urticaria, 
apart  from  the  traumatic  urticaria;  and  this  never  arises  sponta- 
neously. 

This  tendency  is  diminished  by  sedative  douches  (98"  F.)  for 
three  minutes  without  percussion.  High  frequency  currents  may 
also  be  used,  but  generally  have  a  mediocre  result.  In  most  cases  it 
does  not  appear  that  dermographism  has  any  connection  with 
digestive  disorders. 

URTICARIA  AB  INGESTI3. 


Urticaria  ab  ingesfis  is  well  known.  A  few  hours  after  the  inges- 
tion of  certain  articles  of  diet,  tainted  food,  shell-fish,  etc.,  an  attack 
or  urticaria  occurs.  This  begins  as  a  tingling  and  burning  of  the 
skin,  which  becomes  more  and  more  intolerable  and  is  followed  by 
intense  pruritus;  tlie  urticarial  eruption  then  appears  with  red  con- 
fluent, hot  elevations  on  the  trunk  and  limbs,  and  even  on  the 
mucous  membranes  of  the  mouth,  nose  and  throat,  and  no  doubt  in 
tl:e  stomach,  with  vomiting.  This  condition  lasts  for  several  hours, 
new  lesions  arising  as  the  first  fade  away :  they  occur  with  symptoms 
of  more  or  less  marked  febrile  indigestion,  and  sometimes  of  real 
poisoning.  After  10  to  36  hours  the  symptoms  abate  and  gradually 
disappear. 

Treatment  consists  in  evacuation  of  the  stomach  by  emetics  or 
tl:e  stomach  tube,  and  mild  purgation  when  digestion  is  more  ad- 
vanced. The  local  symptoms  are  relieved  by  a  prolonged  tepid  bath. 
During  the  night  the  body  may  be  powdered  with  talc,  placed  in  the 
bed ;  or  glycerine  of  starch  with  carbolic,  acetic  or  tartaric  acid 
( I  per  cent)  and  menthol  ( i  per  cent)  may  be  applied. 

It  may  be  mentioned  in  the  etiology  of  urticaria  ab  ingesfis,  that 
the  same  aliments  do  not  cause  urticaria  in  everyone ;  hence  there 
are  individual  reactions  or  predispositions.  There  are  also  aliments 
which  always  reproduce  urticaria  in  certain  subjects. 


534  URTICARIA. 

MEDICAMENTOUS  URTICARIA. 

Certain  medicaments  cause  in  certain  persons  an  attack  of  urti- 
caria very  similar  to  that  of  alimentary  urticaria.  These  are 
chiefly:  antimony,  and  the  antimonial  preparations;  arsenic,  in  all 
forms,  may  cause  (besides  cutaneous  disorders  caused  by  its  long 
continued  absorption)  an  acute  erythema  in  patches,  a  roseola  or 
urticaria ;  antipyriii  may  give  rise  to  an  erythema  in  placards,  gen- 
erally urticarial  and  pruriginous ;  quinine  causes  more  scarlatiniform 
eruptions;  bromides  may  cause  the  same,  although  the  most  charac- 
teristic lesions  are  papular,  indurated  and  papillomatous ;  chloral 
causes  an  urticarial  pruriginous  erythema  of  the  neck,  mouth  and 
face ;  digitalis  and  its  derivatives  causes  an  erythema  in  patches,  a 
roseola  and  an  erythema  "in  rosettes" ;  copaiba  causes  a  rubeoliform 
and  urticarial  eruption  with  small  elements,  an  eruption  generally 
in  subinvolutive  crops,  when  its  cause  is  not  recognised  and  its  ad- 
ministration continued;  antitoxic  serums  may  cause  an  urticarial 
eruption  within  the  48  hours  following  the  injection,  or  a  roseola 
about  12  days  after  the  injection  (p.  583).  These  eruptions,  in 
spite  of  their  frequent  general  symptoms,  are  never  grave.  Medica- 
mentous  eruptions  disappear  after  the  suppression  of  their  cause. 


VACCINAL  URTICARIA. 

\'accinal  urticaria  appears  from  the  4th  to  the  8th  day  after 
vaccination ;  remains  for  two  or  three  days,  and  disappears  in  a  few 
hours.    It  was  noticed  by  Jenner,  and  is  of  no  importance. 


URTICARIA  OF  CHILDREN. 

The  urticarias  of  children  generally  occur  in  connection  with  diges- 
tive disorders,  without  their  immediate  cause  and  mechanism  being 
alwavs  easy  to  define,  and  without  any  definite  relation  between  the 
eruptive  attacks  of  the  ingested  ailments.  Sometimes  the  urticarial 
attacks  follow  the  ingestion  of  eggs  in  winter,  or  such  articles  as 
haricot  beans ;  at  other  times  recurrent  attacks  of  urticaria  appear 
which  are  attributed  to  food,  because  one  does  not  know  v.hat  else 
to  attribute  them  to. 


URTICARIA.  535 

Urticaria  in  children  may  assume  many  forms.  Sometimes  it 
occurs  as  a  simple  urticaria  of  varying  intensity,  or  with  more  or 
less  developed  elements  (giant  urticaria).  Sometimes  there  is  a 
clear  vesicle  in  the  centre  of  each  spot ;  this  is  the  varicella-prurigo 
of  Hutchinson  (vesicular  urticaria).  On  the  hands  and  feet  urti- 
caria may  even  become  bullous. 

Recurrent  urticaria,  which  at  first  appears  to  be  of  the  normal 
type  in  children  {strophulus  pniriginosus  of  Hardy)  often  becomes 
the  prurigo  of  Hebra.  If  the  prurigo  of  Hcbra  had  the  autonomy 
of  measles,  or  some  other  specific  disease,  and  it  is  not  impossible 
that  it  may  acquire  it  in  the  future,  one  might  say  that  the  prurigo 
of  Hcbra  often  presents  a  primary  phase  of  urticaria.  But  urti- 
carias recurring  like  the  different  forms  of  prurigo  do  not  appear  to 
be  specific  diseases ;  they  are  apparently  simple  syndromes,  or  re- 
actional  conditions  of  the  skin,  which  may  no  doubt  be  transformed 
one  into  the  other.  Thus,  urticaria  is  often  found  mixed  with  acute 
simple  lichen  or  acute  prurigo  of  children,  with  chronic  urticaria  or 
chronic  prurigo,  but  more  often  in  children  than  in  adults. 

In  the  treatment  of  urticaria  the  primar}'  digestive  cause  must 
be  treated,  whenever  this  is  found  with  certainty,  or  even  with 
probability ;  but  it  is  necessary  to  avoid  the  extreme  of  forbidding 
all  kinds  of  nourishment,  without  having  examined  whether  the 
aliments  suppressed  are  harmful ;  for  this  may  lead  to  unnecessary 
malnutrition. 

Treatment  by  milk  diet  must  not  be  considered  as  a  panacea  for 
all  urticarias.  Some  intestines  will  not  tolerate  it  and  form,  with 
the  fatty  and  albuminous  substances  in  the  milk,  toxic  products  of 
decomposition. 

It  appears  very  doubtful,  clinically,  whether  the  paroxysmal  re- 
curring urticarias,  which  behave  like  a  variety  of  the  prurigo  of 
Hcbra,  of  which  they  are  often  only  the  first  stage,  have  any  relation 
to  the  form  of  diet  which  may  be  modified  completely  and  in  ten 
different  ways  without  influencing  the  evolution  of  the  urticaria  or 
the  pruritus.  Urticaria  ab  ingcstis  haunts  the  mind  of  the  physician, 
and  makes  him  believe  that  all  urticarias  are  caused  ab  ingcsta. 
This  is  a  verv  hvpothetical  induction,  and  probably  false. 

The  local  treatment  is  the  same  as  for  acute  urticaria  of  adults 
during  the  attacks.  When  the  urticaria  is  chronic  and  paroxysmal 
the  external  treatment  is  blended  with  that  for  prurigo  of  Hebra 
(P-  549)- 


536  URTICARIA. 

URTICARIA  OF  ADULTS. 

The  essential  urticaria  of  adults  is  characterised  only  by  its 
recurrences.  A  first  attack  is  ahva}s  regarded  as  ab  ingcstis. 
Nevertheless,  certain  persons,  especially  women,  are  liable  to 
periodic  outbreaks  of  urticaria,  in  connection  with  menstruation,  or 
A\  ith  migraine  or  different  nervous  conditions,  anger,  emotion,  etc. ; 
or  at  certain  seasons,  under  the  influence  of  heat  or  cold,  correspond- 
ing with  hay  asthma,  etc.  In  fact,  the  alleged  causes  of  many 
recurrent  urticarias  in  adults  are  not  experimentally  establ'shsd 
and  may  be  mere  coincidences.  In  the  adult,  prurigo  on  the  one 
hand  and  urticaria  on  the  other  are  distinct  cutaneous  reactions 
which  coexist  more  rarely  than  in  children. 

The  considerations  concerning  the  diet  of  children  attacked  with 
urticaria  may  be  applied  to  the  urticaria  of  adults,  in  which  they 
are  equally  true.  The  local  treatment  is  the  same.  When  the  urti- 
caria is  believed  to  be  of  intestinal  origin,  the  administration  of 
such  drugs  as  salol,  benzo-naphthol  and  other  disinfectants  should 
be  avoided,  as  these  may  themselves  give  rise  to  cutaneous 
eruptions. 

Forms  of  Urticaria.  In  the  text  books  different  forms  of  urti- 
are  mentioned : 

(i)  Urticaria  mixed  with  purpura,  or  purpura  urticans,  the 
severity  of  which  is  sometimes  great  and  sometimes  slight  accord- 
ing to  different  authors,  appears  to  vary  considerably  and  to  be 
dependent  on  the  cause  of  the  concomitant  purpura. 

(2)  Urticaria  tuhcrosa  causes  local  areas  of  oedema  as  large  as 
a  hen's  tgg;  the  eruption  is  always  recurrent  and  occurs  in  hypo- 
chondriacs  and   in   the   insane. 

(3)  Urticaria  gigans  may  be  generalised  or  localised  to  a  region 
such  as  the  lips  or  eyebrows;  it  resembles  rather  an  accidental 
oedema  than  a  true  urticaria,  but  has  the  fugacity,  suddenness  of 
appearance,  and  recurrences  of  the  latter. 

(4)  Urticaria  gangrenosa  has  been  described,  with  ooints  of 
necrosis  in  the  centre  of  each  papule ;  it  is  nearly  always  a  localised 
urticaria,  sometimes  recurring  in  situ,  sometimes  forming  an 
abnormal  gangrenous  zona. 

( $)  Urticaria  pigmentosa  is  not  a  true  urticaria  but  a  chronic 
papular  disease,  arising  in  successive  outbreaks   (p.  558). 


VERMINOUS  PARASITIC  DISEASES. 


Scabies 


Fowl's  itch   . 

Phtiriasis    of 
body    .    .    . 


p.  537 


-Vintager's  itch   .   p.  541 


Before  studying  the  pruriginous  dermatological 
diseases  of  the  group  of  lichen-prurigos,  it  is  use- 
ful to  describe  the  parasitic  verminous  diseases 
zvliich  have  a  great  resemblance  to  them,  and  I 
shall  first  describe   the  human  itch 

.    .    .   Afterzvards  the  special  autumn  itch  which' 
is  rural,  or  imported  from  the  country  to  tozvn,  and 
which  is  usually  localised  in  the  folds  and  on  the 
lower  half  of  the  body ^ 

.  .  .  The  itch  of  foivl  pluckers,  or  Fowl's  itch, 
zvliich  only  causes  a  man  a  transient  eruption 
on   the   arms 

/  shall  next  review  the  characters  of  phtiriasis 
of  the  body,  with  its  melanodermia  and  traces  of 
interscapular  scratching 

^  shall   conclude  zvith   the   bites   of  mosquitoesXMosquhoes,    fleas, 
ficas  and  bugs J      bugs P-  543 


P-54-^ 


the 


P-54-2 


SCABIES. 

Scabies,  or  the  itch,  is  a  dermatozoosis  caused  by  a  sarcoptes,  the 
A  cams  scabiei  of  the  family  of  Arachnida.  It  is  a  noctambular 
parasite  and  contagion  seldom  occurs  except  in  bed,  which  justifies 
the  opinion  that  scabies  is  a  venereal  aifection.  The  idea  that  the 
disease  is  contracted  by  simple  contact,  by  shaking  hands,  etc.,  is 
erroneous. 

The  male  parasite  is  rare  on  man  and  the  female  only  is  usually 
seen.  The  female  acarus  digs  a  burrow  in  the  horny  epidermis, 
which  is  formed  exactly  like  a  mole's  gallery,  at  the  end  of  which 
i*"  is  easily  found  and  extracted  with  a  pin.  The  eggs  of  the  acarus 
and  its  foecal  matter  are  as  characteristic  as  the  parasite  itself,  and 
are  found  along  the  burrow.  The  acarus  appears  to  the  eye  as  a 
white  spot.  It  may  be  examined  under  the  microscope  in  a  drop 
of  glycerine  or  Canada  balsam,  without  staining. 

The  contamination  of  one  human  being  by  another  takes  place 
during  nocturnal  contact.  The  first  burrows  in  man  are  usually  on 
the  penis,  and  in  women  around  the  genitals.  The  incubation  of 
the  eggs  takes  15  days,  and  the  first  symptoms  of  itching  occur 
about   three   weeks   after   contamination,   and   increase   every   day. 


538 


VERMINOUS    PARASITIC    DISEASES. 


They  are  specially  marked  around  the  genital  regions,  the  groins, 
axillae,  waist,  elbow,  wrists  (even  on  the  palmar  surface),  in  the 
interdigital  spaces  and  on  the  fingers,  and  on  the  areola  of  the  breast 
in  women.  Except  in  itch  of  animal  origin,  which  is  very  rare,  the 
head  and  neck  are  never  affected. 

The  chief  characteristics  of  the  eruption  are  the  lesions  of  scratch- 
ing, the  small  vesicles  and  excoriated  papules.    On  the  places  most 


Fig.  308.    Female  acarua  (after  Bergh.  X  350.) 


free  from  scratch  marks  the  irregular,  tortuous  burrows  are  marked 
out  by  dirt.  In  very  cleanly  persons  the  burrows  are  hardly  visible, 
but  may  be  made  apparent  by  ink,  which  fills  the  burrows  by 
capillarity.     The  best  marked  burrows  occur  on  the  palm  of  the 


VERMINOUS    PARASITIC    DISEASES.  539^ 

hands,  the  interdigital  spaces,  the  thenar  eminence  and  the  pahiiar 
surface  of  the  wrist. 

The  topography  of  the  lesions  of  scabies  is  significant  and 
diagnostic:  the  same  with  the  fact  of  contagion.  When  husband 
and  wife  both  scratch  themselves,  or  when  several  children  use  a 
common  bed,  the  diagnosis  of  scabies  may  be  made  almost  without 
examination. 

Scabies  may  be  complicated  by  prurigo,  eczema,  streptococcic 
impetigo,  pustular  impetigo  or  erthyma.  Without  exception,  pus- 
tules or  phlyctenules  on  the  palmar  surface  of  the  hand,  in  a  subject 
who  is  pruriginous  on  the  whole  surface  of  the  body,  belong  to  a 
pustular  scabies. 

I  have  described  the  normal  and  accidental  signs  of  scabies  in  each 
region;  on  the  penis  (p.  425);  the  glans  (p.  416);  the  axillae 
(P-  257);  the  elbow  (p.  291);  the  wrists  (p.  329);  the  hands 
(p.  344). 

The  treatment  of  scabies  is  purely  external^  and  consists  in 
sulphur  applications,  the  traditional  ointment  of  Helmerich  modified 
by  Hardy  is  too  strong  and  often  gives  rise  to  traumatic  dermatitis 
of  long  duration : — 

Lard 120  grammes  3j 

Flower     of     sulphur 20  "  gr.  80 

Carbonate     of    potash 10  "  gf-  40 

It  is  better  to  substitute  one  of  the  following  formulas  which  arc 
equally  active  but  less  irritating : — 

(i)   Benzoated  lard 120  grammes  5j 

Precipitated    sulphur 20           "  gr.  80 

Balsam  of  Peru 10          "  gr.  40 

(2)  Glycerine 200  grammes  ,^j 

Precipitated    sulphur 100  grammes  3iv 

Tragacanth i  S^rammeT  ^^^        ^ 

Essence  of  Verveine r           "       J 

\\'ith  these  applications  a  vigorous  friction  is  made  on  the  whole 
of  the  bodv  for  20  minutes.  After  this  the  patient  has  a  soap  bath. 
For  the  next  15  days  oxide  of  zinc  ointment  and  starch  baths  are 

1  It  may  be  mentioned  that  scabies  up  to  the  middle  of  the  19th  century  was 
considered  by  most  physicians  as  a  general  disease;  diathetic  and  depurative. 
This  shews  to  what  errors  doctrinal  preconceived  opinions  .may  lead  in  the 
etiology  of  dermatoses  and  their  treatment,  in  the  absence  of  experimental 
facts. 


540  VERMINOUS    PARASITIC    DISEASES. 

prescribed.  Care  should  be  taken  that  the  patient  who  continues  to 
itch  does  not  make  a  new  apphcation,  thinking  himself  incom- 
pletely cured   (Acarophobia). 

The  rubbing  always  destroys  the  parasites,  but  the  eggs  may 
escape.  In  this  case  a  recurrence  cannot  be  diagnosed  for  three 
W'ceks  after  the  first  rubbing.  A  second  rubbing  may  be  made  8 
days  after  the  first  on  the  moist  irritating  lesions.  In  ill  advised 
cases  5  or  6  rubbings  have  been  made,  causing  an  artificial  derma- 
titis for  3  months. 

]\Iany  different  agents  have  been  prescribed  for  scabies,  such  as 
naphthol  lo  per  cent,  which  is  very  irritating  and  of  mediocre 
therapeutic  value;  balsam  of  Peru,  styrax^  etc.,  mixed  with  an 
equal  quantity  of  oil  of  almonds.  Cases  are  few  in  which  their 
employment  is  any  better  than  the  sulphur  applications,  and  they 
may  give  rise  to  dermatitis  in  the  same  w^ay.  Suppuration  com- 
plicating scabies  is  generally  cured  by  its  treatment.  The  most 
marked  cases  sometimes  require  special  treatment    (p.    lo). 

AUTUMN  ITCH  OR  VINTAGER'S  ITCH. 

Under  this  name  is  designated  the  eruption  caused  by  the  parasite 
of  Trouihidium  holosericnm,  better  known  as  August  or  Vintager s 
itch.  Certain  districts  are  infested  during  the  months  of  July  till 
the  first  frosts  come,  which  destroy  it.  The  parasite  is  a  small  red 
spider,  hardly  visible  to  the  naked  eye,  which  is  annexed  by  sitting 
down  or  even  by  w^alking  in  the  fields. 

The  pruritis  is  intolerable  and  the  scratching  intense  at  the  points 
of  puncture,  which  are  always  follicular.  The  body  is  thus  covered 
in  a  few  days  with  small  excoriations,  each  of  which  remains 
pruriginous  for  several  days. 

In  districts  where  the  eruptions  are  very  common  (Poitou,  Sain- 
tonge,  etc.),  diagnosis  is  not  difficult.  The  eruption  is  more  pro- 
nounced on  the  legs,  and  the  punctures  decrease  in  number  in  the 
upper  parts  of  the  body. 

The  most  simple  treatment  consists  in  brushing  the  body  with  a 

large  brush  moistened  with  : — 

Petroleum  ether "1  T        -. 

Ai     1    1       or  f-aa  oo  grammes  y  a*  5J 

Alcohol  90^° J        ^     ^  J 

Spirit  of  lavender 20  "  3  ss 

Acetic  acid 2  "  gr.  x 


VERMINOUS    PARASITIC    DISEASES  541 

FOWL'S   ITCH. 

Fowl's  itch  in  man  is  an  eruption  of  red  miliary  macule  pre- 
dominating on  the  Hmbs  and  mixed  with  scratch  marks.  It  is 
seldom  observed  except  in  persons  whose  occupation  exposes  them 
to  it  specially ;  those  who  breed  fowls,  those  who  pluck  them  every 
day,  and  those  who  clean  fowl  houses.  It  is  caused  by  the  Der- 
manyssiis  gallincr,  a  small  acarian  parasite  which  does  not  multiply 
on  man.  Fowl's  itch  disappears  in  a  few  days  without  treatment 
when  further  exposure  to  the  parasites  is  avoided. 

PHTHIRIASIS    OF    THE   BODY. 

Typical  cases  when  once  seen  are  never  forgotten.  The  patients 
are  nearly  always  old  and  miserable,  more  or  less  broken  down  and 
cachectic;  or  young  people  having  the  appearance  of  semi-cretins. 
Their  dirty  clothes  exhale  an  evil  odour.  The  body  is  covered  with 
erosions  or  cicatricial  traces  of  erosions  produced  by  the  nails  in 
Imes  parallel  to  the  instinctive  direction  of  the  movements  of 
scratching. 

The  skin  is  melanodermic,  especially  on  the  back  between  the 
shoulders,  on  the  hips,  hypogastric  region,  and  the  external  surface 
and  roots  of  the  four  limbs.  It  is  never  eczematised,  but  often 
lichenised,  and  covered  also  with  the  pustules  and  cicatrices  of 
former  impetigo  and  erythema. 

The  lice  and  eggs  are  not  seen  on  the  body,  but  a  few  eggs  may 
occur  exceptionally  along  the  hairs  of  the  body  in  very  hairy  indi- 
viduals. The  eggs  usually  occur  in  the  folds  and  seams  of  the 
clothes.  They  are  w^hite  and  shining  and  may  be  found  in  immense 
numbers,  all  contiguous,  forming  scintillating  bands  in  the  inside 
folds  of  the  clothes.  The  louse  is  white,  larger  and  longer  than  the 
brown  head  louse,  and  is  also  found  in  the  clothes. 

In  cases  where  the  phthiriasis  is  not  well  marked,  or  at  its  onset, 
diagnosis  must  be  made  by  the  topography  of  the  lesions,  which  are 
grouped  in  different  regions  to  those  affected  by  prurigo ;  the  latter 
have  a  preference  for  the  surfaces  of  the  limbs  and  are  more  equally 
dispersed  on  the  body  than  phthiriasis.  The  appearance  of  the  lesions 
of  phthiriasis  when  scratch  marks  predominate,  without  the  papular 
lesions  which  they  provoke,  is  also  characteristic.  But  the  question 
is  settled  bv  examination  of  the  clothes,  which  should  be  made  with 


542  VERMINOUS    PARASITIC    DISEASES. 

extreme  minuteness  in  doubtful  cases,  by  separating  all  the  folds, 
at  the  bottom  of  which  the  parasites  are  always  lodged. 

Diagnosis  may,  however,  be  difficult  and  cases  occur  in  old 
women,  even  with  high  social  position,  which  are  diagnosed  as 
senile  prurigo  and  treated  as  such.  It  is  certain  that  phtiriasis  of 
the  body  may  in  certain  cases  be  remarkably  tenacious,  in  spite  of 
the  greatest  care.  In  the  immense  majority  of  cases,  however,  it 
is  a  dirt  disease  which  cleanliness,  daily  change  of  linen,  and  baking 
the  clothes  removes  in  a  few  davs. 


PARASITISM    OF    MOSQUITOES,    FLEAS    AND    BUGS. 

]\Iosquito  bites  are  not  common  in  our  climate  except  on  the 
]Mediterranean  Coast.  The  punctures  of  culex  pipiens  cause  an 
urticarial  papule,  centred  by  the  puncture.  When  the  pimctures 
are  frequent  they  cause  diffuse  oedema  of  the  region.  The  lesions 
are  very  pruriginous  and  for  several  days  the  slightest  touch 
revives  the  pruritus. 

Flea  bites  (p.  242)  cause  a  minute  red  purpuric  spot,  sometimes 
circled  with  pink.  Thousands  of  them  may  occur  on  the  same 
subject,  causing  pseudo-purpura.  The  principal  localisations  on  the 
neck  and  forearms  assist  diagnosis,  which  the  elementary  lesions 
suffice  to  confirm. 

Bug  bites  are  identical  with  flea  bites,  with  a  purpuric  macular 
and  violet  areola,  but  each  puncture  is  urticarial  like  the  mosquito 
bite.  Diagnosis  is  only  doubtful  when  the  punctures  are  confluent, 
when  they  may  simulate  an  exanthem;  but  in  this  case  the  patient 
•can  hardlv  be  ignorant  of  the  cause. 


PAPULAR  DERMATOSES. 

PRURIGOS  LICHENS. 

Elementary  Lesion:  The  Papule. 


Lichens  and  Pru- 
rigos in  gen- 
eral   p.  544 

Urticarial  ele- 
ment     p.  545 

-Papule  of  prurigo  p.  545 
Pruritus    ....  p.  546 


Pigmentation 


of 

.  p. 546 


The  old  lichens,  the  prurigos  of  the  present  day, 
form  a  large  class  of  generalised  dcriiiatoses.  Be- 
fore studying  the  different  types  I  shall  point  out 
their  elementary  characteristics,  zvhicli  are  three 
in  number 

/  shall  first  study  the  objective  element,  the 
papule.  Sometimes  this  takes  the  form  of  the  urti- 
carial papule 

.  .  .  Sometimes  it  takes  the  form  of  a  small 
hard  element,  slightly  conical  and  often  exulcerated 
by  scratching;   the  papule  of  prurigo 

Lastly,  a  constituent  element  of  the  nosograph- 
ical  group  is  pruritus;  this  is  most  constant  but 
its  origin  is  still  very  obscure 

When  I  have  studied  each  primary  element  of 
the  lichen-prurigos,  I  shall  consider  their  secondary 
elements,  for  example  pigmentation J  ^ 

.    .    .   Glandular    enlargement,    zvhich    is    never-.   .  ,     .  . 
,        ^  LAdenitis     ....  p.  546 

absent [  ^  '^^ 

.  .  .  And  the  secondary  symptomatic  lesions, 
well  characterised  objectively,  zvhich  are  called 
lichenisation    and    ecscmatisation 

Having  completed  the  study  of  the  constituent 
elements  of  the  prurigo-lichcns,  I  shall  consider 
the  pure  clinical  forms;  and  first  the  principal  one, 
the   prurigo    of   Hebra 

Aftenvards  the  prurigo  of  adults,  zchich  is  gen-\P  r  uvi  g  os       of 
erally    regional    (lichen    circumscriptus    of    Vidal)]      adults     ....   p.  55o 

And  that  rare  and  singular  affection  almost 
special  to  the  minus  habens,  knon'n  as  lichen  ob- 
stnsus    of    Vidal 

Finally  senile  prurigo,  so  peculiar  in  its  char- 
acters and  even  in  its  negative  characters  .... 

/   shall   mention    the    clinical   synthesis   of    /n^'l  Diathetic    Prurigo 
lichen-prurigoie  named  by  Besnier,  Diathetic  prurigos      of  Besnier    .    .   p.  55^ 


Lichenisation    . 
Eczematisation 


p.  547 
P-548 


Prurigo  of  Hebra  p.  549 


Lichen      obstusus 
of  Vidal    .    .    .   p. 551 

Senile  Prurigo    .   p.  55^ 


544 


PAPULAR    DERMATOSES. 


^  1  Symptomatic  Pru- 
1      rigos p.  553 


Lichen   planus   of 
Wilson  .  .    .    .  p.  553 


/  shall  conclude  with  a  few  words  on  the  symp- 
tomatic and  secondary  prurigos,  which  are  very 
distinct    from    the    preceding , 

In    the   old   classification   of   lichens  were   con-' 
founded    affections    essentially    different   from    the 
prurigos.    For   instance,    lichen   planus,   of  which 
we  shall  speak  next,  and  of  zvhich  the  autonomy 
is  certain 

.    .    .  Porokeratosis,    Zi'hich     resembles    annular') 
lichen    planus j  Porokeratosis      .  p.  555 

.  .  .  and  lichen  planus  corneus  atrophicus.l^  Lichen  planus 
which  is  very  different  from  true  lichen  planus  I  corneus  atro- 
m  many  ways J      phicus    .    .    .    .  p.  555 

.    .    .   and  lichen  scrofulosorutn,  zvhich  is  a  pap-1 


ular   tuberculide   occuring   in   disseminated   islai 


scrofulo- 


P-  503 


tuberculides      .   p.  556 
syphil- 


(d escribed  previously) J      ^^^^^ 

.    .    .   and    eruptions    of    papulo-necrotic    tuber-  ] 
culides  with  cicatricial  evolution;  acnitis,  /^o//tV/w,  |.-^^P"'°  "  "^^''°^"^ 
etc 

In  conclusion  I  shall  reviezu  in  a  fczu  zvords  the\Fapu\a.r 
papular  eruptions  of  secondary  syphilis J      ides p.  556 

.    .    .   The  characters  of  the  papular  eruption  of")  Generalised     xan- 
the  yellow  indolent  elements  of  xanthoma  ...    .J      thoma    . 

.    .    .    The    characters    of    the    chronic    />a/'M/ar  T  Pigmentary 
eruption  known  as  pigmentary  urticaria J      caria   .    . 

.    .    .   and  the  not  papular  but  papuloid  hyper-' 
keratotic    follicular    elements    of    pityriasis    rubra 
pilaris  of  Devergie-Besnier 


P-557 


urti- 


P-558 


Pityriasis 
pilaris 


rubra 


P-  55'^ 


The  last  morbid  types  can  only  be  described  along  with  the 
preceding  ones  by  specifying  their  heterogeneous  nature,  for  the 
prurigo-lichens  are  much  more  allied  to  the  urticarias  and  eczemas 
than  to  the  last  nine  morbid  types  mentioned. 

PRURIGO    LICHENS. 


Pruritus  without  definite  cause  and  the  cutaneous  lesions  which 
accompany  it,  constitute  one  of  the  most  difficult  chapters  in  der- 
matology. We  shall  endeavour  to  explain  clearly  what  is  known, 
even  at  the  expense  of  being  somewhat  schematic. 

Excluding  from  the  group  which  follows  the  pruritus  which  are 
only  secondary  to  a  clearly  defined  dermatosis,   such  as   scabies. 


PAPULAR    DERMATOSES.  545 

there  remains  a  whole  morbid  group  in  which  are  found  in  different 
degress:  (i)  pruritus  without  definite  cause,  and  for  this  reason 
called  protopathic;  (2)  the  hard  acuminated  papule  of  prurigo, 
which  is  very  special,  preceded  or  not  by  an  urticarial  lesion. 
Among  these  three  elements,  pruritus,  papule  of  prurigo,  papule  of 
urticaria,  the  urticarial  element  may  predominate,  but  it  is  generally 
little  marked  or  disappears  quickly.  The  pruritus  and  the  papules 
also  remain.  Soon  a  new  element,  hyperpigmentation,  is  added;  and 
then  all  the  fundamental  elements  are  united  which  constitute  what 
are  called  the  prurigos;  the  old  lichens  of  the  French  school. 

THE  URTICARIAL   ELEMENT. 

In  the  prurigo-lichens  the  urticarial  element  may  at  first  pre- 
dominate, especially  in  children.  It  resembles  an  attack  of  simple 
urticaria,  but  the  papules  fade  while  the  crises  of  pruritus  persist, 
and  soon  each  element  of  urticaria,  excoriated  or  not,  gives,  place 
in  its  centre  to  a  papule  of  prurigo,  around  which  the  urticarial 
reaction  persists  in  a  variable  degree.  The  nervous  erethism  may 
persist  for  a  long  time  and  only  manifest  itself  by  a  cutis  anserina, 
caused  by  the  erector  muscles  of  the  hairs. 

Sometimes  in  the  course  of  very  persistent  prurigos  certain 
attacks  of  prurigo  are  urticarial  and  others  not. 

THE    PAPULE    OF    PRURIGO. 

The  papule  of  prurigo  occurs  after  scratchings,  a  fact  which  is 
clinically  established ;  "  in  prurigo  the  pruritus  is  pre-eruptive" 
(Jacquet).  It  must  not,  however,  be  concluded  that  the  lesion  is 
caused  by  scratching,  for  it  may  pre-exist  before  the  scratching 
without  being  visible  to  the  naked  eye.  In  fact  every  biopsy  which 
I  have  performed  on  a  pruriginous  spot  in  prurigo  shews  definite 
histological  lesions. 

In  any  case  the  papules  of  prurigo  have  the  form  of  a  cone  with 
a  flat  top,  from  i  to  3  millimetres  in  diameter  and  less  than  a 
millimetre  high.  They  are  firm  and  not  soft.  They  may,  in  differ- 
ent cases,  be  scanty,  abundant,  disseminated  or  agminated,  more  or 
less  coarse,  or  deformed.  Many  are  decapitated  by  scratching  and 
the  summit  is  occupied  by  a  minute  blood  crust,  a  millimetre  and 

35 


546  PAPULAR   DERMATOSES. 

a  half  in  diameter.  The  fate  of  the  papule  of  prurigo  is  very 
variable;  sometimes  it  persists  for  some  time,  sometimes  it  disap- 
pears, often  leaving  behind  it  a  pigmentary  spot,  which  remains 
for  a  long  time.  When  the  papule  persists  it  changes  in  character. 
The  old  papule  of  prurigo  is  flattened,  smooth  and  shiny,  and  con- 
stitutes with  many  similar  papules,  juxtaposed  or  fused  together, 
the  placard  of  lichenification  of  Brocq.  In  this  form  it  may  last 
for  years. 

PRURITUS. 

Pruritus  is  the  most  mysterious  element  of  the  morbid  com- 
plexus  which  we  are  describing.  Even  if  we  admit  it  to  be  the 
cause  of  the  papule  and  the  elements  derived  from  it,  its  cause  and 
nature  are  quite  unknown.  It  may  be  localised  or  generalised,  and 
is  most  often  paroxysmal,  with  evening  exacerbations.  It  com- 
mences when  the  body  is  stripped  naked  before  going  to  bed,  and 
may  be  often  repeated  during  the  night.  Other  paroxysms  may 
occur  in  the  day  time.  The  pruritus  may  be  slight  and  ignored  by 
the  patient;  in  other  cases  it  is  severe  and  may  lead  to  suicide.  In 
some  cases  it  is  incessant,  in  others  remittant.  Although  the  ap- 
parent lesions  are  proportional  to  the  intensity  of  the  pruritus,  this 
is  not  always  the  case. 

PIGMENTATION. 

Hyperpigmentation  of  the  skin  in  the  pruriginous  varies  in 
degree,  but  is  rarely  absent.  There  is  a  diffuse  pigmentation  which 
occurs  on  the  whole  pruriginous  surface,  and  a  hyperpigmentation 
localised  to  each  pre-existing  papule  of  prurigo,  or  to  each  scratch 
mark,  which  survives  them  for  a  long  time.  It  helps  to  make  the 
aspect  of  prurigos  polymorphous  and  is  not  of  great  importance  in 
the  diagnosis  of  chronic  prurigos.  It  appears  to  be  independent  on 
scratching.  We  know  that  repeated  traumatism  increases  the 
functional  activity  of  the  cells  submitted  to  it.  Thus,  hyperpigmen- 
tation is  comparable  to  the  cellular  hyperplasia  which  forms  the 
papule. 

ADENITIS. 

Adenitis  is  never  absent  in  prurigo  and  has  not  been  sufficiently 
studied.     Generalised  prurigo  gradually  give  rise  to  a  polymicro- 


PAPULAR    DERMATOSES.  547 

adenitis  which  resembles  that  of  secondary  syphillis,  in  the  number 
of  glands  affected,  their  increase  in  size,  their  hardness  and  their 
absence  of  pain  on  pressure.  I  mention  this  fact  because  it  is  indis- 
putable and  I  do  not  pronounce  on  the  pathogeny  which  gives  rise  to 
it.  To  attribute  it  to  the  result  of  microbial  infections  produced  by 
scratching  is  acceptable  in  the  prurigo  of  Hebra,  which  is  very 
often  eczematised  or  infected;  but  these  glands  are  quite  as  gener- 
alised, indurated  and  increased  in  volume  in  senile  prurigo,  although 
eczematisation  and  pustulation  are  never  produced  during  its  course, 
and  it  occurs  at  an  age  when  inflammatory  adenitis  is  rare  and  little 
marked.    The  question  requires  further  investigation. 


LICHENISATION. 

The  permanent  organisation  of  the  old  papules  of  prurigo  and  the 
multiplication  of  these  papules  in  contiguity,  constitute  the  placard 


Fig.  309.     Specimen   of   pure   lichenification. 
(Brocq's  patient.     Photo  by   Sottas.) 

which  Brocq  has  described  under  the  name  of  lichenification,  and  of 
which  he  has  shewn  the  nosological  value. 

The  lichenified  {Brocq),  or  lichenised  (Besnier)  placard  is  con- 
stituted by  a  thick  cutaneous  infiltration  which  doubles  at  least  the 
folding  of  the  skin.    The  fold  is  hard  and  does  not  pit  on  pressure. 


548  PAPULAR    DERMATOSES. 

The  surface  is  formed  of  quadrillatecl  patches  in  the  form  of  shiny, 
smooth  cushions  (Fig.  209),  separated  from  each  other  by  fine 
shallow  folds,  which  are  never  fissured.  As  Brocq  has  remarked, 
this  lichenification  is  a  common  process  of  cutaneous  reaction,  and 
chronic  eczemas  may  form  lichenised  patches  in  different  points. 
"Eczema  makes  lichens"  (Bacin),  but  lichenification  may  be  com- 
pletely constituted  without  eczema,  under  the  sole  influence  of  pru- 
ritus :  this  is  pure  lichenification.  However  pruritus  does  not  create 
lichenification  on  all  skins. 

Personally,  I  only  regard  lichenification  and  eczematisation  of 
any  origin  as  two  common  processes  in  chronic  dermatitis.  Some- 
times this  dermatitis  is  exudative,  causing  ecaematisation ;  some- 
times it  is  dry  and  hyperplastic,  causing  lichenification.  And  even 
when  tlie  latter  occurs  in  the  pure  state,  constituting  the  chief 
symptom  of  a  morbid  type  (neuro-dermatitis  of  Brocq)  it  only 
represents  a  symptom.  These  cutaneous  reactions  are  determined 
by  certain  traumatisms ;  but  we  are  ignorant  of  the  exact  causes 
which  produce  either,  or  one  rather  than  the  other. 


ECZEMATISATION. 

Eczematisation  (Besnicr)  is  the  assemblage  of  lesions  and 
objective  symptoms  commonly  attributed  to  eczema  (p.  561);  an 
epidermatitis  at  first  finely  vesicular,  then  diffusely  exudative, 
accompanied  by  inflammatory  symptoms  which  are  generally  of 
moderate  intensity.  The  influence  of  external  traumatisation  in  the 
production  of  the  phenomenon  "eczematisation"  is  more  or  less 
evident,  and  nearly  always  recognisable.  Eczematisation,  as  well 
as  lichenisation,  is  a  banal  phenomenon,  which  does  not  belong 
properly  to  any  dermatosis,  but  may  complicate  a  great  number. 
It  appears  to  be  a  common  form  of  cutaneous  reaction.  It  does  not 
appear  to  me  to  be  justifiable  to  make  a  disease  of  lichen-prurigo. 
or  of  eczema.  They  are  syndromes.  Eczematisation  is  the  juoist 
dermatitis,  as  lichenisation  is  the  dry  dermatitis.  They  are  generally 
associated,  and  difTer  only  in  their  relative  proportions  in  prurigo 
and  in  eczema.  No  objective,  subjective,  or  anatomical  symptom 
differentiates  the  eczematisation  of  a  prurigo  from  the  eczematisa- 
tion in  eczema,  or  in  any  disease  which  may  be  accompanied  by  it. 


PAPULAR   DERMATOSES.  549 

PRURIGO    OF    HEBRA. 

The  prurigo  of  Hebra  is  an  affection  of  childhood  and  adolescence. 
It  commences  at  an  early  age,  by  more  or  less  generalised  urticarial 
attacks  which  are  often  difficult  to  diagnose  at  first,  and  do  not 
constitute  the  state  of  prurigo  till  after  three  or  four  years.  Cases 
may  be  described  as  severe,  slight  and  medium.  The  pruritus  is 
intense,  and  occurs  chiefly  in  nocturnal  crises.  The  face,  the  natural 
folds,  the  fore-arms  especially,  the  whole  of  the  limbs  or  body  are 
more  or  less  covered  with  small  papules  of  disseminated  prurigo ; 
scratch  marks ;  pigmentary  patches  in  the  place  of  former  lesions ; 
and  very  often,  especially  on  the  face  and  in  the  natural  folds,  the 
prurigo  is  accompanied  by  more  or  less  marked  and  chronic  ecze- 
matisation,  with  thickening  of  the  skin.  Lichenisation  may  occur 
even  in  children  without  eczematisation. 

The  course  of  the  disease  is  paroxysmal  and  seasonal,  it  often 
shews  annual  remissions  and  recrudescences,  and  may  be  said  to  be 
continuously  remittent.  In  different  cases  the  relative  proportions 
of  one  of  the  constituent  elements  predominates ;  at  the  onset  it  is 
the  pruritus  and  the  urticarial  element,  with  eczematisation;  for, 
speaking  generally,  eczematisation,  the  moist  dermatitis,  is  more 
common  in  youth,  and  lichenisation,  the  dry  dermatitis,  in  middle 
or  advanced  age. 

In  different  cases  the  glands  are  more  or  less  increased  in  size 
and  sensitive.  The  general  health  usually  remains  good  except  in 
cases  of  pyodermic  and  furuncular  attacks,  which  are  exceptional 
and  transient.  As  the  child  grows  older  it  often  suffers  from  ade- 
noids and  chronic  rhinitis,  and  has  coarse  lips  and  nose.  This  is 
the  so-called  strumous  appearance,  and  certain  authors  consider  the 
papule  of  prurigo  of  Hebra  as  a  benign  scrofulide. 

The  cause  of  this  disease  is  quite  unknown.  It  improves  with 
age  and  the  crises  diminish  in  number  and  intensity.  A  few  isolated 
crises  may  occur  during  the  following  years.  Hence  the  disease  is 
nearly  always  cured,  but  the  patient  may  retain  a  pruritus  without 
lesions.  In  severe  cases  the  prurigo  of  Hebra  remains  chronic  and 
becomes  attenuated  without  being  cured. 

Treatment  is  palliative  and  symptomatic.  High  frequency  cur- 
rents are  indicated  whenever  there  is  a  high  arterial  tension ;  but 
this  is  not  the  rule.  The  X-rays  have  often  an  evident  antipru- 
riginous  action  ;  but  this  is  specially  the  case  in  symptomatic  pru- 


SS2  PAPULAR   DERMATOSES. 

kles  of  the  face,  when  the  pruritus  is  pronounced  in  this  situation; 
a  few  excoriations  of  the  skin;  hyperpigmentation  giving  the  skin 
an  ashy  grey  appearance ;  lastly,  an  increase  in  the  size  of  the  glands, 
especially  at  the  root  of  the  limbs,  axillae  and  groins.  These  are 
the  principal  characters. 

This  pruritus  generally  accompanies  early  arterio-sclerosis ;  but 
all  cases  of  arterio-sclerosis  are  not  pruriginous.  As  a  rule,  how- 
ever, in  these  morbid  conditions  the  lowering  of  arterial  tension  has 
a  favourable  influence  on  the  pruritus.  For  this  reason  unipolar 
high  frequency  treatment  is  the  method  to  be  preferred  at  first.  The 
X-rays,  used  without  a  diaphragm  so  that  the  irradiation  covers 
the  greatest  possible  extent  of  surface,  should  be  tried  next.  Aledic- 
amental  applications  have  only  a  mediocre  value  in  these  cases. 

DIATHETIC   PRURIGO    OF    BESNIER. 

It  is  obvious  that  the  preceding  morbid  groups  have  no  criterion  to 
establish  their  autonomy.  They  may  be  described  as  above  under 
three  headings :  prurigo  of  Hcbra,  local  prurigo  of  adults  and  senile 
prurigo;  but  a  child  may  present  acute  non-recurrent  prurigo-lichen 
simplex,  and  also  the  adult;  the  prurigo  of  Hebra  is  seen  in  the 
adult;  and  the  adult  may  present  a  prurigo  which  increases  with 
age,  but  cannot  be  called  senile  at  the  age  of  40. 

Hence,  we  may  consider  the  prurigos  with  prolonged  evolution 
as  belonging  to  a  single  morbid  individuality,  and  unite  them  under 
the  name  of  diathetic  prurigo  (Besnier).  This  term  thus  connects 
the  chronic,  exulcerating,  paroxysmal  pruriginous  dermatites,  in 
which  the  multiform  cutaneous  lesions  which  they  present  during 
their  whole  evolution  always  remain  banal — that  is  to  say,  limited 
simply  to  lichenisation  and  eczematisation. 

This  general  point  of  view  shews  how  the  dermatological  chapter 
of  prurigos  remains  obscure,  and  will  continue  so  as  long  as  their 
causes  are  not  better  defined. 

I  have  already  stated  that  I  have  a  tendency  to  regard  eczemas 
and  lichens  as  only  the  dry  and  moist  forms  of  a  cutaneous  reaction 
of  the  same  unknown  origin.  For  it  seems  that  histology  may  make 
the  papule  of  lichens  an  abortive  vesicle  of  eczema,  or  the  vesicle 
of  eczema  a  lichen  papule,  the  vesicular  centre  of  which  has  become 
visible.  But  this  is  not  the  place  for  controversy  concerning  doc- 
trines which  are  hypothetical  and  conjectural. 


PAPULAR   DERMATOSES.  553 

SYMPTOMATIC    PRURITUS    AND    PRURIGO. 

A  certain  number  of  diseases,  or  syndromes,  of  very  different 
origin  and  nature  are  accompanied  by  intense  pruritus.  The  pruri- 
tus of  icterus  is  one  of  the  best  known  and  most  common.  But  I 
cannot  give  here  the  differential  history  of  all  the  pruriginous  der- 
matoses. When  the  diagnosis  of  prurigo  is  to  be  determined  and 
its  triad  of  symptoms  recognised,  pruritus,  papule  and  lichenisation, 
it  must  be  remembered  that  certain  diseases  have  a  preliminary  pru- 
riginous phase.  The  chief  of  these  dermatoses  is  mycosis  fungoides 
(p.  627).  A  diagnosis  of  essential  prurigo  should  never  be  made 
without  considering  this  possible  confusion. 


LICHEN   PLANUS   OF   ERASMUS   WILSON. 

The  old  name  of  lichen  remains  applied  to  two  diseases.  The 
pityriasis  rubra  pilaris  of  the  French  school  is  known  in  other  coun- 
tries as  lichen  ruber  acuminatus.  Under  the  name  of  lichen  ruber 
planus  or  lichen  planus  is  designated  an  eruptive  disease  of  slow 
progress  and  special  characters,  described  by  Erasmus  Wilson. 

Lichen  planus  is  thus,  not  a  variety  of  the  lichen-prurigos,  but  an 
affection  probably  as  specific  as  the  pityriasis  rosea  of  Gibert,  pso- 
riasis, or  varicella.  Its  cause  is  unknown  and  its  nature  disputed, 
but  its  autonomy  is  hardly  contestable  so  long  as  the  histology  of 
its  lesions  renders  them  distinctive. 

Lichen  planus  generally  arises  spontaneously  and  not  on  pre- 
existing lesions.  I  have,  however,  once  seen  it  occur  in  the  middle 
of  the  lesions  of  psoriasis,  and  upon  them ;  and  another  time  on  the 
lesions  of  an  intense  medio-thoracic  pityriasis,  and  by  transforma- 
tion in  situ  of  these  lesions.  I  have  also  seen  its  eruptions  preceded 
by  a  primary  placard  identified  with  that  of  pityriasis  rosea  (p.  521). 
lUit  these  facts  are  rare.  Generally,  lichen  planus  begins  by  a  crop 
of  lesions  which  are  similar  to  all  those  which  follow.  The  first 
lesions  arise  on  the  wrists,  hands,  forearms  and  on  the  body.  They 
may  remain  localised  for  a  long  time,  but  usually  the  eruption  is 
complete  and  generalised  in  a  few  weeks. 

The  lesion  is  a  papule,  the  size  of  the  macules  of  measles,  yellow- 
ish red,  sharply  raised,  with  a  smooth  flat  surface  and  semi-solid 
consistency.    The  papules  are  often  grouped  around  a  larger  lesion 


552  PAPULAR   DERMATOSES. 

kles  of  the  face,  when  the  pruritus  is  pronounced  in  this  situation ; 
a  few  excoriations  of  the  skin;  hyperpigmentation  giving  the  skin 
an  ashy  grey  appearance ;  lastly,  an  increase  in  the  size  of  the  glands, 
especially  at  the  root  of  the  limbs,  axillae  and  groins.  These  are 
the  principal  characters. 

This  pruritus  generally  accompanies  early  arterio-sclerosis ;  but 
all  cases  of  arterio-sclerosis  are  not  pruriginous.  As  a  rule,  how- 
ever, in  these  morbid  conditions  the  lowering  of  arterial  tension  has 
a  favourable  influence  on  the  pruritus.  For  this  reason  unipolar 
high  frequency  treatment  is  the  method  to  be  preferred  at  first.  The 
X-rays,  used  without  a  diaphragm  so  that  the  irradiation  covers 
the  greatest  possible  extent  of  surface,  should  be  tried  next.  Medic- 
amental  applications  have  only  a  mediocre  value  in  these  cases. 

DIATHETIC   PRURIGO    OF    BESNIER. 

It  is  obvious  that  the  preceding  morbid  groups  have  no  criterion  to 
establish  their  autonomy.  They  may  be  described  as  above  under 
three  headings :  prurigo  of  Hchra,  local  prurigo  of  adults  and  senile 
prurigo;  but  a  child  may  present  acute  non-recurrent  prurigo-lichen 
simplex,  and  also  the  adult;  the  prurigo  of  Hehra  is  seen  in  the 
adult;  and  the  adult  may  present  a  prurigo  which  increases  with 
age,  but  cannot  be  called  senile  at  the  age  of  40. 

Hence,  we  may  consider  the  prurigos  with  prolonged  evolution 
as  belonging  to  a  single  morbid  individuality,  and  unite  them  under 
the  name  of  diathetic  prurigo  (Besnier).  This  term  thus  connects 
the  chronic,  exulcerating,  paroxysmal  pruriginous  dermatites,  in 
which  the  multiform  cutaneous  lesions  which  they  present  during 
their  whole  evolution  always  remain  banal — that  is  to  say,  limited 
simply  to  lichenisation  and  eczematisation. 

This  general  point  of  view  shews  how  the  dermatological  chapter 
of  prurigos  remains  obscure,  and  will  continue  so  as  long  as  their 
causes  are  not  better  defined. 

I  have  already  stated  that  I  have  a  tendency  to  regard  eczemas 
and  lichens  as  only  the  dry  and  moist  forms  of  a  cutaneous  reaction 
of  the  same  unknown  origin.  For  it  seems  that  histology  may  make 
the  papule  of  lichens  an  abortive  vesicle  of  eczema,  or  the  vesicle 
of  eczema  a  lichen  papule,  the  vesicular  centre  of  which  has  become 
visible.  But  this  is  not  the  place  for  controversy  concerning  doc- 
trines which  are  hypothetical  and  conjectural. 


PAPULAR    DERMATOSES.  553 

SYMPTOMATIC    PRURITUS    AND    PRURIGO. 

A  certain  number  of  diseases,  or  syndromes,  of  very  different 
origin  and  nature  are  accompanied  by  intense  pruritus.  The  pruri- 
tus of  icterus  is  one  of  the  best  known  and  most  common.  But  I 
cannot  give  here  the  differential  history  of  all  the  pruriginous  der- 
matoses. When  the  diagnosis  of  prurigo  is  to  be  determined  and 
its  triad  of  symptoms  recognised,  pruritus,  papule  and  lichenisation, 
it  must  be  remembered  that  certain  diseases  have  a  preliminary  pru- 
riginous phase.  The  chief  of  these  dermatoses  is  mycosis  fungoides 
(p.  637).  A  diagnosis  of  essential  prurigo  should  never  be  made 
without  considering  this  possible  confusion. 


LICHEN   PLANUS   OF  ERASMUS   WILSON. 

The  old  name  of  lichen  remains  applied  to  two  diseases.  The 
pityriasis  rubra  pilaris  of  the  French  school  is  known  in  other  coun- 
tries as  lichen  ruber  acuminatus.  Under  the  name  of  lichen  ruber 
planus  or  lichen  planus  is  designated  an  eruptive  disease  of  slow 
progress  and  special  characters,  described  by  Erasmus  Wilson. 

Lichen  planus  is  thus,  not  a  variety  of  the  lichen-prurigos,  but  an 
affection  probably  as  specific  as  the  pityriasis  rosea  of  Gibert,  pso- 
riasis, or  varicella.  Its  cause  is  unknown  and  its  nature  disputed, 
but  its  autonomy  is  hardly  contestable  so  long  as  the  histology  of 
its  lesions  renders  them  distinctive. 

Lichen  planus  generally  arises  spontaneously  and  not  on  pre- 
existing lesions.  I  have,  however,  once  seen  it  occur  in  the  middle 
of  the  lesions  of  psoriasis,  and  upon  them ;  and  another  time  on  the 
lesions  of  an  intense  medio-thoracic  pityriasis,  and  by  transforma- 
tion in  situ  of  these  lesions.  I  have  also  seen  its  eruptions  preceded 
by  a  primary  placard  identified  with  that  of  pityriasis  rosea  (p.  521). 
But  these  facts  are  rare.  Generally,  lichen  planus  begins  by  a  crop 
of  lesions  which  are  similar  to  all  those  which  follow.  The  first 
lesions  arise  on  the  wrists,  hands,  forearms  and  on  the  body.  They 
may  remain  localised  for  a  long  time,  but  usually  the  eruption  is 
complete  and  generalised  in  a  few  weeks. 

The  lesion  is  a  papule,  the  size  of  the  macules  of  measles,  yellow- 
ish red,  sharply  raised,  with  a  smooth  flat  surface  and  semi-solid 
consistency.     The  papules  are  often  grouped  around  a  larger  lesion 


554  PAPULAR   DERMATOSES. 

of  the  same  morphological  nature.    These  groups  are  all  of  the  same 
form,  which  they  only  lose  when  the  eruption  becomes  cohesive. 

Scratching  produces  a  linear  series  of  papules  along  its  whole 
length.  On  the  costal  regions  the  papules  are  disposed  in  a  series 
in  the  direction  of  the  ribs,  especially  on  the  posterior  surface  of  the 
body.  The  eruption,  which  is  very  often  cohesive  on  the  body, 
becomes  confluent  at  certain  points  (the  internal  surface  of  the 
fore-arm,  the  back  of  the  hands,  etc.).  These  patches  have  the 
same  relation  to  lichen  planus  that  Hchenisation  has  to  prurigo;  the 
homology  is  clear,  but  the  placard  of  lichen  planus  is  as  distinctive 
as  its  papules.  The  thin  hard  placard,  of  a  pale  violet  red  colour, 
is  quadrillated  by  thin  grey  arborescences,  which  divide  the  surface 
in  all  directions.  Lichen  planus  has  characters  which  are  as  special 
as  its  lesions.  It  is  seen  on  the  palm  of  the  hand,  the  sole  of  the 
foot,  in  the  mouth  and  on  the  tongue ;  and  on  the  genital  organs 
it  may  cover  the  penis  and  even  the  glans. 


rig.  211.    Confluent  papular  elements  of  lichen  plantis. 
(Brooq's  pat.ent.    Photo  by  Sottas.  ) 

Lichen  planus  assumes  different  forms.  Its  eruption  may  be  sub- 
acute and  limited  to  single  papular,  or  even  erythematous  elements, 
and  all  the  papules  have  a  rose-violet  periphery.  The  papule  often 
presents  a  thin,  horny  cap,  the  abnormal  development  of  which 
creates  a  form  of  hyperkeratosis.  In  certain  cases  the  papules  are 
large  and  hypertrophic ;  in  other  cases  the  distribution  of  the  papules 
seems  to  follow  a  nerve  trunk;  in  others  it  is  circinate.  All  these 
forms,  except  the  erythematous,  are  rare.  The  eruption  is  never 
accompanied  by  general  symptoms.  The  functional  symptoms  are 
most  variable;  the  chief  one  is  pruritus,  which  may  be  excessive. 


PAPULAR    DERMATOSES..  555 

intolerable,  or  hardly  sensible;  sometimes  there  are  distressing  ting- 
ling and  burning  sensations.  As  a  rule  these  symptoms  are  mod- 
erate and  soon  abate.  The  duration  of  the  disease  is  from  2  to  4 
months ;  sometimes  a  year  or  more.  In  the  course  of  the  disease 
there  may  be  relapses,  but  I  have  not  seen  recurrence,  although  sev- 
eral authors  have  mentioned  the  possibility  of  it.  When  the  stage 
of  resolution  arrives  all  the  lesions  may  be  replaced  by  a  grey  or 
black  pigmentation,  which  is  very  slow  to  disappear. 

This  disease  has  no  specific  treatment.  Xo  general  treatment  is 
satisfactory,  and  none  has  any  constant  appreciable  effect.  Treat- 
ment is  limited  to  the  diminution  of  functional  symptoms,  especially 
of  the  pruritus  when  this  is  severe,  by  tepid  douches  (95°  to  98°  F.) 
of  three  minutes'  duration,  as  little  percussive  as  possible,  daily  or 
twice  daily  (Jacquet).    Local  applications  have  a  moral  effect. 

POROKERATOSIS. 

Porokeratosis  is  a  rare  disease  analogous  to  annular  lichen  planus, 
the  history  of  which  is  only  outlined  {Respighi,  Mibelli).  Its  seats 
of  election  are  the  extremities,  the  back  of  the  hands  and  feet,  the 
forearms,  legs,  genital  organs  and  buccal  mucosa.  The  elementary 
lesion  is  a  slightly  raised  horny  papule,  surrounded  by  a  hyperkera- 
totic  circle  from  which  it  is  separated  by  a  groove.  When  the  lesion 
has  become  large,  it  is  irregularly  cyclic.  In  the  centre  the  skin  is 
somewhat  atrophied,  smooth  or  squamous,  wath  a  periphery  of  horny 
cohesive  elevations  resembling  the  elementary  papule. 

The  evolution  of  this  disease  is  chronic,  the  lesions  remain  sta- 
tionary, do  not  increase  in  number,  and  remain  relatively  discrete 
and  few  in  number.  The  nails  may  be  affected  with  onychorrhexis 
(P-  383)-  In  the  mouth  the  lesions  resemble  those  of  lichen  planus, 
but  are  not  constant. 

The  cutaneous  lesions  may  retrogress  and  undergo  spontaneous 
cure,  leaving  a  small  atrophic  cicatrix.  No  treatment  has  any  effect. 
The  active  keratolytics,  such  as  salicylic  acid,  pyrogallic  acid,  etc., 
may,  however,  be  tried. 

LICHEN    PLANUS    CORNEUS    ATROPHICUS. 
The  relationship  of  lichen  planus  corneus  atrophicus  to  the  lichen 
plasus  of  Wilson  does  not  appear  to  me  to  be  clinically  demonstrated. 
I  have  not  studied  the  lesions  histologically. 


556  PAPULAR   DERMATOSES. 

Lichen  planus  corneus  is  a  rare  affection,  never  generalised  (at 
least  if  the  hyperkeratotic  form  of  the  lichen  of  Wilson  is  not 
included,  which  would  appear  an  error  in  nosography),  always 
localised  to  a  few  regions  of  the  body  and  formed  of  discrete,  dis- 
seminated elements,  chronic  in  situ,  pruriginous,  increasing  or  retro- 
gressing slowly,  and  disappearing  by  cicatrisation  These  charac- 
ters differ  from  those  of  lichen  of  Wilson. 

The  usual  situations  of  horny  lichen  are  the  leg  and  scalp ;  some- 
times a  few  elements  are  seen  on  the  elbow  and  thigh.  They  form 
conglomerations  of  hard,  brown,  irregular  hyperkeratotic  papules; 
each  of  the  groups  having  an  oblong  or  elongated  form.  When  the 
lesion  has  existed  for  some  time  a  cicatrix  forms  at  one  of  its 
extremities. 

Treatment  consists  in  destruction  by  the  galvano-cautery,  or  the 
application  of  a  plaster  of  cinnabar  and  red  oxide  of  lead. 


PAPULAR    ACNEIFORM    TUBERCULIDE    WITH 
CICATRICIAL   EVOLUTION. 

There  is  a  generalised  eruption  which  has  the  same  relation  to 
tuberculosis  that  the  syphilitic  papular  eruption  has  to  syphilis. 

Diagnosis  is  often  confused  at  first,  as  the  two  eruptions  resem- 
ble one  another  topographically.  There  is  the  same  dispersion  of 
the  elements  all  over  the  body  with  a  predominance  on  the  limbs. 
The  elements  consist  of  reddish  brown,  or  purple,  irregular  papules, 
from  2  to  5  millimetres  in  diameter,  and  i  to  2  millimetres  in  height, 
often  agglomerated  in  twos  and  threes,  or  disseminated  in  variable 
numbers,  lasting  for  months,  and  disappearing  by  atrophy.  This 
atrophy  is  marked  by  a  stellate  depression  in  the  centre  of  each 
papule.  As  soon  as  the  papule  has  disappeared  the  cicatrix  rests  on 
the  brownish-violet  mark  of  the  former  papule.  Finally  the  colour 
itself  disappears  after  several  months  and  the  cicatrix  remains ;  pale 
brown  or  white.  Local  treatment  is  nil,  and  general  treatment  con- 
sists in  the  diet  and  hygiene  of  external  tuberculosis. 


SECONDARY   PAPULAR   SYPHILIDES. 

I   shall  only  mention  here  the  profuse   eruption  of  round,   flat, 
copper-coloured  papules  of  secondary  syphilis,  which  is  early  recog- 


PAPULAR    DERMATOSES. 


557 


nised  by  its  diffusion,  which  does  not  spare  any  part  of  the  body, 
and  by  the  concomitance  of  the  classical  secondary  lesions,  poly- 
adenitis, remains  of  hard  chancre,  etc. 

GENERALISED    XANTHOMA. 

Generalised  xanthoma  will  be  described  with  the  tumours  of  the 
skin  (p.  632).  It  is  constituted  by  a  multitude  of  small,  yellow,  soft 
papular  lesions,  which  may  be  numerous  or  discrete,  predominating 


Fig.  212.     Generalised   Xanthoma    of   the    buttocks. 
(Besnier's    patient.      St.    Louis    Hosp.    Museum.      No.    4043.) 


in  the  natural  folds  and  points  of  friction,  the  elbows,  buttocks,  back, 
hands  and  fingers. 

Nothing  resembles  the  peculiar  elements  of  xanthoma,  with  their 
pinkish  yellow  colour,  and  their  form  in  pastilles  or  papules.    The 


558  PAPULAR    DERMATOSES. 

eruption  is  chronic  and  painless,  and  can  never  be  mistaken  when 
once  seen.    For  treatment  see  page  130. 

URTICARIA    PIGMENTOSA. 

Under  this  false  name  is  designated  a  rare,  chronic,  papular  pig- 
mentary disease,  of  which  the  following  is  a  precise  description. 

It  commences  in  the  course  of  the  first  year  by  successive  crops, 
which  at  first  resemble  urticaria.  They  form  elevations,  which  are 
somewhat  urticarial  in  appearance,  but  of  a  deep  red  colour.  They 
appear  at  first  on  the  trunk,  then  on  the  head  and  then  on  the  limbs. 
When  mature  they  do  not  disappear,  but  their  papulation  remains 
stationary,  or  may  even  increase,  and  their  colour  becomes  a  deep 
brown.  Other  crops  of  eruption  arise  which  follow  the  same  course, 
so  that  after  a  year  the  eruption  is  generalised.  The  skin  is  "spot- 
ted" and  covered  with  papular  spots  of  different  heights,  the  flatter 
ones  being  smooth  and  the  more  elevated  folded  on  the  surface. 
There  is  a  macular  form  less  papular  than  usual,  and  a  nodular  or 
tuberous  form  in  which  the  lesions  are  more  projecting.  It  appears 
that,  at  the  time  of  appearance  of  the  eruption,  the  skin  is  always 
dermographical  (p.  533),  but  the  elevations  thus  produced  are  transi- 
tory and  not  pigmented. 

The  disease  when  mature  remains  stationary,  but  it  is  said  to 
sometimes  retrogress  and  disappear.  I  have  seen  one  case  remain 
after  16  years  without  any  retrogression,  and  this  seems  to  be  the 
rule.    The  cause  is  unknown  and  the  treatment  nil. 

PITYRIASIS    RUBRA    PILARIS. 

The  reader  might  refer  here  for  the  description  of  pityriasis  rubra 
pilaris,  mistaking  for  papules  its  numerous  horny  follicular  cones, 
which  may  cover  the  entire  body  and  give  it  the  appearance  of  a 
file.  It  is  described  with  the  squamous  diseases  on  page  528  and 
figured  on  page  369. 


VESICULAR  AND   EXUDATIVE   DERMATOSES. 


Elementary  lesion.    The  Vesicle. 


The  vesicular  and  exudative  dermatoses  have") 
eczema  as  their  prototype.  The  importance  of  this  I 
affection   requires   some   details I 

/  shall  study  successively  the  vesicle  of  eczema  1 
and  the  eczematous  pore  which  succeeds  it  .    .    .  J 

Next  the  eczematous  placard  which  results  from  1 
the  confluence  of  primary  vesicular  elements. .    .    .J 

Next,  pruritus  and  the  scratching  which  it  pro-' 
vokes,   and   the   objective   transformation  zvhich   it 
causes    in    eczematous    lesions 

/  shall  study  next  the  exudation  and  crusts  of 
tlie  eczematous  placards 

Lastly,  the  phase  of  dcssication  and  desquama- 
tion which  terminates  the  evolution  of  the  eczema- 
tous placard   

The   assemblage    of    these    phenomena   has   been' 
designated  by  the  symptomatic  name  of  ecsematisa- 
tion.     This   may   be   slight   and   abortive,   medium 
or  intense;   acute  or  chronic 

Chronic  eczematisation  is  very  analogous  to 
chronic  lichenisation,  and  I  shall  describe  what  is 
known  concerning  the  relationship  of  these  tzvo 
morbid   types 

The  etiology  of  eczema  is  still  not  well  known,'] 
and  I  shall  point  out  the  obscurities J 

/  shall  revieiv  the  chief  forms  of  eczema,  the\ 
number  of  which  may  be  multiplied  to  infinity  .    .  J 

And  I  shall  conclude  zvith  treatment  of  eczema  1 
in  general;  that  of  the  different  localised  forms  V 
having    been   studied   already  .    .    . J 

Other  affections  have  the  vesicle  as  their  ele-\ 
mentary   lesion,   such   as   miliaria J 


Definition    of    ec- 
zema    p.  560 

Vesicle  of  eczema  p.  560 

Eczematous      pla- 
card     p.  560 

Pruritus     ....   p.  561 

Exudation     and 
crusts     ....   p.  561 

Dessication  .   .    .   p.  561 


And  vesicular  urticaria 


Varicella  is  considered  elsewhere  (p.  600),  but' 
I  shall  mention  the  chief  differential  characters   .    .  - 

The  same  with  pustular  impetigo  and  phlyctc-' 
nular  impetigo  (p.  7),  concerning  which  I  shall 
only  say  a  fevt;  words , 


Eczematisation   .   p.  561 

Eczematisation 
and     lichenisa- 
tion      P-  561 

Etiology   of   ecze- 
ma    p.  562 

Forms  of  eczema  p.  563 

Treatment    of    ec- 
zema    p.  564 

■  Miliaria      ....   p.  565 

Vesicular      urti- 
caria     p.  566 

Varicella    ....   p.  566 
Generalised        im- 


petigo 


p.  566 


56o  VESICULAR    AND    EXUDATIVE    DERMATOSES. 

The   same   with   pemphigus   foliaceus,   the   char-  1 
acters  of  which  zvill  he  briefly  mentioned,  as  it  is  l          P    & 
described  with  the  bullous  dermatoses  (p.  6io)     .        ^ceus p.  5 


ECZEMAS. 

"Apyretic  and  non-contagions,  eczema  is  characterised  by  tlie 
eruption,  on  different  i^arts  of  the  skin,  of  small  vesicles,  generally 
close  together  or  grouped,  with  little  or  no  inflammation  at  their 
base ;  it  is  generally  the  effect  of  an  irritation  of  internal  or  external 
origin,  and,  in  subjects  in  whom  the  skin  is  constitutionally  irritable 
it  finds  occasional  causes  in  the  most  varied  agents,"     (Batcman.) 

To  this  definition  it  may  be  added  that  eczema  is  a  pruriginous 
dermatosis,  polymorphous  according  to  the  nature  and  age  of  the 
case  examined,  localised,  diffuse  or  generalised,  acute  and  recurring, 
or  chronic  and   paroxysmal.     Its   cause   remains  unknown. 

Whatever  the  origin,  situation  or  form  of  an  eczema,  it  is  usually 
possible  to  recognise  the  elementary  vesicular  lesion;  even  in  the 
forms  known  as  red  eczema,  dry  eczema,  or  crackled  eczema. 

Eczema  thus  requires  the  description  of:  (i)  the  eczematous 
vesicles  and  the  eczematous  placard  which  they  constitute;  (2)  the 
pruritus  which  accompanies  them  and  alters  the  lesions  by  scratch- 
ing! (3)  the  exudation  and  crust;  (4)  the  phase  of  dessication, 
desquamation  and  return  to  normal,  which  terminates  the  crises  of 
eczema. 

I.  The  eczematous  vesicle.  This  should  first  be  examined 
in  eczema  of  the  hands  and  feet,  where  it  is  as  large  as  a  hemp-seed, 
easily  visible,  clear,  acuminated,  hard  and  difficult  to  rupture.  Every- 
where else  it  is  as  small  as  the  eye  of  a  needle  and  quickly  ruptured 
by  scratching,  so  that  in  at  least  half  the  cases  it  is  less  easy  to  see 
the  vesicle  than  its  remains. 

These  remains  form  a  red  spot  the  size  of  a  printer's  full  stop, 
which  exudes  considerably  after  scratching.  Under  a  lens  this  point 
shows  the  rete  mucosum  exposed  by  disappearance  of  the  horny 
layer.  It  is  thus  a  minute  epidermic  exudative  exulceration,  which 
may  be  termed  the  ecaematons  pore;  the  remains  of  the  former 
vesicle. 

The  eczematous  placard  is  formed  by  the  cohesion  of  a  multitude 
of  eczematous  vesicles,  or  of  the  pores  which  remain  after  their  rup- 
ture.    In  the  centre  of  these  placards  the  lesions  are  confluent ;  at 


VESICULAR    AND    EXUDATIVE    DERMATOSES.         561 

the  periphery  they  become  irregular,  so  that  a  true  eczematous  placard 
has  nearly  always  diffuse  borders.  An  eczematous  surface  may  be 
so  large  as  to  cover  a  whole  limb  or  as  small  as  a  patch  of  herpes ; 
but  in  the  latter  case  there  are  several  patchss  irregularly  scattered. 

2.  Pruritus.  Pruritus  accompanies  the  appearance  of  the 
lesions.  This  appearance  is  more  rapid  and  more  quickly  seen  than 
in  the  prurigos ;  so  that  it  is  more  difficult  to  say,  in  the  case  of 
eczema,  that  the  pruritus  is  pre-emptive.  The  lesions  generally 
appear  at  first  under  this  horny  epidermis;  pruritus  causes  decapita- 
tion of  the  vesicle  and  transforms  it  into  the  eczematous  pore.  The 
vesicular  placard  becomes  an  exudative  placard.  Scratching  com- 
bined with  epidermic  maceration  decorticates  the  horny  epidermis, 
between  the  eczematous  pores,  over  the  whole  surface  of  the  placard, 
which  becomes  pink  and  smooth  ;  but  even  then  the  eczematous  pores 
remain  visible  as  red  points. 

3.  Exudation  and  Crusts.  The  liquid  which  exudes  from  the 
eczematous  pores  is  adhesive  to  the  finger  and  stiffens  the  linen ;  it 
is  colourless  and  appears  to  irritate  the  neighbouring  epidermis ;  it  is 
very  concresible  and  forms  amber  crusts.  These  crusts  are  puncti- 
form  at  the  orifice  of  each  pore  if  the  exudation  is  scanty,  and  resem- 
bles crystals  of  amber.  In  some  cases  the  exudation  may  be  abun- 
dant and  the  yellow  opaque  crust  covers  the  whole  placard  like  parch- 
ment, intersected  in  all  directions  by  cracks ;  this  crust  is  adherent 
and  its  removal  renew-s  the  exudation. 

4.  Dessication,  desquamation,  restitution.  If  the  eczematous 
outbreak  is  benign,  the  epidermis  is  restored  under  the  crust,  which 
falls  and  is  followed  by  slight  desquamation.  The  epidermis  then 
becomes  normal ;  for  eczema  never  forms  cicatrices. 

Eczematisaticn.  Abortive  eczematisation.  In  this  case  the 
clinical  picture  may  be  indistinct  and  hardly  recognisable.  For 
instance,  certain  young  girls  present  on  the  face  slight  attacks,  of 
variable  intensity,  of  the  eczema  described  on  page  12,  some  of 
which  shew  "between  skin  and  flesh"  10  to  15  vesicles  w^hich  may  be 
left  after  scratching.  The  exudation  is  infinitesimal  and  the  wiiole 
attack  is  over  in  a  week. 

Medium  eczematisation  is  that  which  we  have  just  taken  as  the 
type  for  the  elementary  descriptions  of  eczema ;  but  it  may  occur  in 
all  degrees. 

Chronic  eczematisation  is  in  reality  a  recurrent  eczematisation 
without  intermission  ;  the  acute  or  subacute  attacks  are  reproduced 
36 


S62  VESICULAR    AND    EXUDATIVE    DERMATOSES. 

before  the  former  ones  have  disappeared.  In  this  way  an  infiltra- 
tion of  the  whole  skin  is  constituted,  permanently  raised  above  the 
surface.  The  placard  of  chronic  eczematisation  continues  to  differ 
from  the  placard  of  lichenisation,  in  that  it  is  redder,  more  cedema- 
tous,  less  "neoplastic,"  softer  to  the  touch,  less  stable  in  situ,  less 
smooth  on  the  surface,  because  the  surface  is  often  excoriated,  moist 
or  exudative.  But  it  is  impossible  to  regard  these  differences,  and 
the  corresponding  histological  differences,  as  specific,  and  not  to 
-closely  connect  these  two  modes  of  reaction  of  the  skin  with  each 
other.  In  my  opinion  they  are  two  different  aspects  of  the  same 
process.  The  chronic,  pruriginous,  banal  dermatites  may  be  dry, 
forming  prurigo-lichen ;  or  moist,  forming  eczema. 

Is  eccenia  a  diseased  Under  these  circumstances  we  may  question 
whether  prurigo  or  eczema  are  distinct  diseases,  or  if  the  two  words 
should  not  be  abolished  in  favour  of  the  words  lichenisation  and 
€czematisation.  In  my  opinion  the  words  prurigo  and  eczema  only 
represent  two  symptoms;  two  objective  forms  of  the  cutaneous  reac- 
tion to  chronic  irritation,  "external  or  internal  in  certain  irritable 
skins"  {Bateman).  But  this  question,  being  controversial,  must  not 
detain  us  longer. 

Artificial  dermatites,  "eczematons"  or  "eczematiform."  The  opin- 
ion which  I  have  just  enunciated  receives  considerable  support  from 
the  study  of  the  chronic  artificial  dermatites  of  the  extremities  (p. 
341),  which  are  indistinguishable,  in  their  symptoms,  progress,  and 
histological  lesions,  from  chronic  eczema  of  apparently  non-trau- 
matic origin. 

Evolution  of  eczema.  ,^he  evolution  of  eczema,  much  more  than 
its  symptoms  and  lesions,  tends  to  give  it  a  special  autonomy,  and  to 
constitute  it  as  a  morbid  entity,  for  eczema  is  acutely  recurrent,  or 
chronically  paroxysmal.  It  is  only,  apparently,  a  transient  affec- 
tion. 

Etiology  of  eczema.  Nearly  all  authors  who  have  studied  eczema, 
at  any  rate  in  France,  agree  that  the  subjects  of  chronic  eczema  pre- 
sent organic  disorders,  the  alternation  or  the  coincidence  of  which 
with  the  outbreaks  of  eczema  is  remarkable ;  for  instance,  asthma, 
chronic  bronchitis,  migraine,  attacks  of  haemorrhoids,  etc.  On  the 
other  hand  it  may  be  said  that  the  old  eczemas  occur  in  old  people, 
and  that  the  latter  are  rarely  free  from  complaints,  even  when  they 
are  not  eczematous.  In  any  case  these  alternations  and  coincidences 
are  verv  diverse  and  not  clearlv  -defined ;  and  if  the  accessorv  causes 


VESICULAR    AND    EXUDATIVE    DERMATOSES.  563 

of  eczema  in  certain  cases  may  be  remarkable,  the  true  cause  and 
the  physio-pathological  mechanism  of  eczema  in  general  remain  to 
be  discovered. 

Forms  of  eczema.  Acute  vesicular  eczema,  spontaneous  or 
provoked,  is  the  type  of  the  genus ;  but  the  forms  of  eczema  are  very 
numerous.  I  shall  not  speak  of  those  which  are  altered  by  their 
situation;  palmar  eczema  (p.  360);  peri-ungual  eczema  (p.  Z77^ '■> 
eczema  of  the  folds  of  flexion  (p.  314)  ;  eczema  of  the  breast  (p. 
491),  etc.;  but  only  of  the  forms  of  eczema  which  are  objectively 
distinct  in  themselves,  whatever  their  situation. 

There  are  plackards  of  eczema  ruhrum,  very  slightly  vesicular 
which  consist  of  a  red,  hot  infiltration  with  a  dry  desquamating  sur- 
face. This  form  is  common  on  the  legs  and  face,  and  around  the 
eyelids.     This   form   of   eczema   is   generally   localised. 

There  are  dry  and  crackled  eczemas,  very  often  provoked  by  chem- 
ical irritants,  which  occur  on  the  face  and  forearms  and  also  very 
often  on  the  legs,  in  which  the  vesicular  element  is  so  reduced  that  it 
is  necessary  to  examine  the  skin  with  a  lens  under  the  squames  to 
discover  the  eczematous  pores  (Fig.  204,  p.  523). 

There  are  hyperkeratotic  eczemas  which  may  occur  on  all  the  four 
limbs,  but  especially  on  the  fingers  and  toes,  hands  and  feet. 

It  is  not  surprising  that  other  and  autonomous  affections  besides 
the  common  moist  or  dry  secondary  dermatitis  which  covers  them 
and  prevents  recognition,  have  been  confused  with  eczemas,  espe- 
cially when  chronic,  lichenised  and  deformed. 

Infected  eczema  is  less  common  than  might  be  expected,  or  at 
least  there  are  few  cases  altered  so  much  by  infection  as  to  render 
them  unrecognisable.  The  infections  are  streptococcic  (p.  575)  and 
staphylococcic  (p.  569).  The  symptoms  of  these  pyoderatites  may 
be  mixed  with  those  of  eczema,  but  it  is  usually  possible  to  determine 
if  the  pyodermatitis  has  caused  the  eczematous  reaction,  or  whether 
the  primary  eczema  has  been  secondarily  infected. 

(a)  The  -figured  eczemas,  or  what  pass  by  this  name,  are  not 
always  eczemas;  the  eczema  marginatum  of  Hehra  was  inguinal 
trichophytosis  (p.  266)  and  erythrasma  (p.  265)  :  the  seborrhocic 
eczema  of  Uuna  includes  steatoid  pityriasis  of  the  scalp  (p.  215)  or 
medio-thoracic  region  (p.  473)  with  cases  of  super-seborrhoeic 
psoriasis  (p.  476),  or  true  psoriasis,  or  even  cases  of  streptococcic 
intertrigo  (pp.  259  and  264),  etc. 


564  VESICULAR    AND    EXUDATIVE    DERMATOSES. 

(b)  Sometimes  a  dermatitis  is  figured  because  it  results  from 
the  eczematisation  of  a  pre-existing  figured  dermatosis ;  as  the  spots 
of  pityriasis  rosea,  after  treatment  with  sulphur,  may  be  seen  to 
become  eczematised  one  by  one. 

(c)  Or,  a  figured  eczematous  dermatitis  may  be  provoked  by 
traumatism  without  any  known  reason  for  its  configuration ;  thus 
desquamative  dermatitis  may  follow  the  irritation  of  scabies,  on  the 
thighs  and  the  whole  body. 

(d)  Lastly  there  are  true  figured  eczemas,  for  their  trichophytoid 
circles  on  the  back  of  the  hands  (p.  342)  may  accompany  a  t}pical 
amorphous  eczema  of  the  body. 

Nothing  is  known  of  the  causes  of  this  configuration.  To  regard 
these  eczemas  as  primarily  or  secondarily  microbial,  and  as  assum- 
ing a  geometrical  figure  because  they  are  microbial,  is  a  hypothesis 
supported  only  by  comparison  with  trichophytosis,  pityriasis,  etc., 
and  not  by  experimental  investigation. 

Treatment  of  eczema.  There  is  not  a  single  method  of  treat- 
ment for  eczema,  but  a  thousand,  which  proves  that  there  is  not  a 
single  good  one.  With  regard  to  the  internal  treatment  of  eczema 
it  is  first  necessary  to  classify  them. 

The  classification  of  eczemas,  in  my  opinion,  has  not  been  at- 
tempted in  a  sufficiently  synthetic  manner.  The  eczemas  of  infancy, 
mostly  of  alimentary  origin  (p.  2),  are  not  the  same  as  those  of 
adolescence,  which  appear  to  be  connected  with  a  form  of  chlorosis 
(p.  12).  Also  there  is  a  whole  category  of  eczemas  of  malnutrUion 
in  old  emaciated  persons,  which  are  cured  by  superalimeniation, 
contrary  to  what  is  everywhere  said  and  written. 

Under  these  circumstances  a  fixed  and  unchangeable  diet  is  not 
indicated  in  eczema.  This  would  attribute  to  eczema  a  uniform 
physiological  mechanism  and  identical  causes,  w^hich  is  not  sup- 
ported by  facts. 

In  every  case  an  eczema,  especially  when  it  persists  or  recurs,  im- 
poses a  complete  examination  of  the  patient  and  analysis  of  his 
urine,  etc. ;  for  no  harm  can  be  done  by  correcting  as  far  as  possible 
everything  abnormal  that  is  found.  Rut,  in  the  absence  of  satisfac- 
tory etiological  theories  of  eczema,  the  true  treatment  is  so  far 
external,  and  this  still  remains  very  variable. 

The  acute  intolerant  forms  require  moist  dressings  (Besuier), 
repeated  at  least  twice  a  day,  and  made  with  simple  boiled  water, 
decoctions  of  elder,  etc.     Potato  starch  poultices  are  preferable  for 


VESICULAR    AND    EXUDATIVE    DERMATOSES.  565 

eczemas  of  small  extent.  These  are  the  best  antiphlogistic  meas- 
ures known.  During  the  acute  period,  when  the  local  temperature 
•of  a  patch  of  eczema  is  raised,  no  local  application  is  tolerated  nor 
has  any  useful  action. 

Nevertheless,  among  the  useful  local  applications  in  acute  eczema, 
that  of  super-heated  air  may  in  the  future  become  a  practical  and 
satisfactory  method. 

When  the  local  temperature  has  fallen,  many  applications  may  be 
used;  in  the  first  place  pastes  with  carbonate  of  bismuth,  oxide  of 
zinc  ( I  in  4).  When  the  eczema  is  semi-squamous,  with  fatty  crusts, 
or  when  it  originates  in  a  natural  fold,  weak  oil  of  cade  ointments 
are  well  supported  and  often  give  excellent  results: — 

Oxide   of  zinc ^  -^ 

Oil  of  cade haa  5  grammes  I     ^a  5ii 

Lanoline J  J 

Vaseline -O  grammes  5j 

Chronic  or  sub-acute  eczemas  do  well  with  applications  of  nitrate 
of  silver  ( i  in  20  to  i  in  10),  alternated  wdth  zinc  paste.  Traumatic 
eczemas  require  the  suppression  of  their  causes. 

Eczemas  of  the  extremities  are  very  tenacious  and  often  require 
vigorous  treatment  by  strong  doses  of  keratolytic  agents ;  salicylic 
acid.  I  in  20 ;  chrysarobin,  I  in  30  to  I  in  40.  1  hese  have  been  men- 
tioned in  treating  of  the  regions  in  which  they  occur  (p.  342),  and 
for  this  reason  this  paragraph  is  limited  to  generalities. 


SUDORAL    MILIARIA. 

In  the  course  of  pyrexias,  especially  at  the  time  of  defervescence 
which  precedes  the  cure,  sometimes  in  normal  health  during  the  hot 
season,  or  after  a  transient  febrile  attack,  appears  sudoral  miliaria. 
The  element  is  a  vesico-pustule,  smaller  than  a  millet-seed,  spheri- 
cal, and  resembling  a  pearl  placed  on  the  skin ;  each  being  circled 
hy  a  red  areola  which  soon  disappears.  The  eruption  of  thousands 
of  these  small  vesicles  covers  the  skin  of  the  thorax,  abdomen,  and 
€ven  the  limbs. 

This  eruption  is  only  of  importance  in  the  benign  prognosis 
which  it  signifies  for  the  disease  in  the  course  of  which  it  appears. 
It  lasts  about  two  days  and  requires  no  treatment. 


566  VESICULAR    AND    EXUDATIVE    DERMATOSES. 

VESICULAR   URTICARIA. 

In  vesicular  urticaria,  which  is  rare,  the  urticarial  element  pre- 
dominates, and  the  vesicular  elevation  is  produced  in  the  middle  of 
the  papule.  This  vesicle  occurs  on  each  urticarial  papule  or  on  most 
of  them.  The  diagnosis  of  vesicular  urticaria  is  only  made  when 
its  existence  is  observed.    The  treatment  is  that  of  urticaria  (p.  536). 

VARICELLA. 

Varicella  is  described  on  page  600.  It  is  an  exanthematous 
fever,  so  benign  that  the  febrile  state  may  pass  unnoticed.  The  char- 
acteristic bullous  elements  are  then  opened  by  scratching,  or  ulcer- 
ated, and  resemble  an  impetigo  with  elements  disseminated  all  over 
the  body.  It  usually  occurs  in  infancy.  The  diagnosis  is  confirmed 
by  the  presence  of  the  characteristic  multilobular  bulla. 

GENERALISED    IMPETIGO. 

An  apparently  generalised  impetigo  is  usually  varicella.  Pus- 
tular impetigo  (p.  569)  is  nearly  always  localised  to  the  scalp  (p. 
183)  and  the  hairy  regions,  and  is  only  generalised  when  it  pre- 
cedes general  furunculosis  (p.  571).  Phlyctenular  impetigo  (p. 
7)  is  always  localised  to  the  face,  fingers,  back  of  fhc  hands  and 
wrists,  and  disseminated  elements  on  the  body  are  scanty ;  3  to  10 
at  the  most.  When  impetigo  becomes  generalised  it  is  in  the  ulcer- 
ated form  of  ecthyma,  in  growing  infants  or  in  cachectic  subjects 
(PP-  573  and  574). 

PEMPHIGUS    FOLIACEUS. 

This  rare  disease  is  better  placed  among  the  erythodermic  and 
bullous  diseases  than  among  the  vesicular  (p.  610).  It  is  a  red  der- 
matosis occurring  at  middle  age.  The  whole  surface  of  the  body  is 
aflfected  insidiously  and  remains  of  a  deep  red  colour.  At  first  sight 
it  resembles  the  pityriasis  rubra  of  Hcbra  (p.  590),  but  when  the 
finger  is  applied  to  the  skin  it  removes  the  horny  layer,  which  is 
separated  by  moisture  from  the  rest  of  the  skin.    Later  on  the  body 


VESICULAR    AND    EXUDATIVE    DERMATOSES.  567 

becomes  covered  with  soft,  flat,  wrinkled  bullae,  which  give  rise  to 
abundant  squanies.  It  is  a  disease  which  causes  slow  cachexia  and 
terminates  in  death  after  10  to  15  years.  Treatment  is  only  pallia- 
tive. 

VARIA. 

I  shall  not  refer  here  to  dyshidrosis,  because  it  is  an  affection 
which  is  limited  to  the  extremities ;  nor  to  :;ona,  which  may  occur  in 
any  region  of  the  body,  but  which  has  been  described  in  its  most 
interesting  and  most  frequent  localisations;  opthalmic  zona  (p.  131)  ; 
intercostal  zona  (p.  483)  ;  nor  to  the  groups  of  recurrent  herpes, 
which  may  also  occur  everywhere,  but,  of  which  the  most  inter- 
esting localisations  have  been  mentioned;  the  lips  (p.  76),  and  the 
genital  organs  in  both  sexes  (pp.  422,  426,  439). 


SUPPURATIVE  DERMATITIS. 
STAPHYLO-PUSTULE    AND    STREPTO-PHLYCTENULE. 

This  chapter  will  be  devoted  to    the    suppurative  epiderinatites, 
which  have  two  common  agents,  the  staphylococcus  and  the  strep- 
tococcus, each  presenting  a,  specific  and  special  lesion  from  which 
numerous   clinical   types   are   derived. 


The  first  of   these   lesions  is   the  staphylococcic^ 
pustule,  a  primary  pustule,   usually   ostio-follicularV^^^^^'^^^^'^'^'^'^^'^ 
and  centred  by  a   hair J      ^ 

We   have  seen   innumerable   derivations   of   this~\ 
in  several  regions;  one  of  the  principal  being  /'!(;--!- Furuncle   .    .    . 
uncle I 

.    .    .  and  the  agglomeration  of  furuncles  callcd^ 
carbuncle J-Carbuncle     .    . 

.    .    .   and  the  sequel  of  furuncle,  knozcn  as  fnr-']  Furuncular    ab- 


P-569 
P-569 


P-  570 


:y 


P-57I 


.    .    .  and   the  generalised   eruption   zvhich   fur- 
imcle    may    create,   espcciallv   in    certain   states   ^H  Generalised       iur- 
malnutrition J      ""culosis 

All  these  morbid  types  have  for  their  immediate] 
€ause    the    ostio-follicular    staphylo-pustule,    .,i,/„v/i  L  disseminated  pus- 


ihcy  follozi' ■ I      tulation 

The  staphylococcus  may  cause  secondary  infec- 


P-57I 

P-572 
P-572 


tion  of  lesions  tuhich  ivere  not  at  first  pustular  .    .  J  Pustules  of  acne 

Lastly,  in   certain  states  of  physiological  misery' 
<and   after   certain   traumatisms,   furuncle   may   en-    Ecthyma     of     Wil- 
iarge,  and  become  transformed  into  an  ulcer,  zvhich 
■constitutes  the  primary  ecthyma  of  IVillan  . 

The  second  element  of  pyodermatitis  is  the 
streptococcic  phlyctunule.  ZK.'hich  is  at  first  clear, 
then  turbid  and  then  suppurative 

IVe   have  studied   numerous  clinical   forms  and' 
derivatives  of  this;  I  shall  only  mention  the  forms 
which  may  become  generalised,  such  as  the  ulcer- 
ative streptococcic  phlyctenule,  the  rupia  of  Bate- 
man  or  the  ecthyma  of  the  authors  of  to-day  . 

.  .  .  and  an  acute  streptococcic  epidcrmatitis 
li'hich  certain  authors  interpret  as  an  infected  and 
impetiginous  eczema titis p.  575 


Ecthyma     of 
Ian   .   .    .    . 


Streptococcic 
phlyctenule 


P-  572 


P-573 


Rupia 
man 


of      Bate- 


P-574 


Acute  streptococ- 
cic epiderma- 
titis  


SUPPURATIVE    DERMATOSES.  569 

.  .  .  also  a  chronic  streptococcic  epidennatitis  ]  Chronic  strepto- 
zvhicli,  according  to  some,  is  only  a  chronic  eczema  I  coccic  epider- 
kept    up    by   permanent   impetiginisafion niatitis    ....   p.  576 

Lastly  I  shall  mention  the  secondary  impetigini-\ 
sation  of  pre-existing  cutaneous  lesions |Tmpetig.nisation     p.  5/6 


STAPHYLOCOCCIC  PUSTULE. 

There  are  two  common  agents  of  cutaneous  suppuration,  the 
staphylococcus    albus    and    aureus,    and    the    streptococcus. 

The  lesion  of  the  staphylococcus  is  a  round,  raised  pustule,  of  a 
greenish  yellow  colour,  containing  thick  pus.  This  pustule  gen- 
erally occupies  the  orifice  of  a  hair  follicle,  and  may  open,  or  dry 
without  opening.  The  crust,  after  falling,  often  leaves  a  minute 
circular  cicatrix. 

This  lesion  is  the  element  of  pustular  eruptions  of  all  situations; 
the  impetigo  of  BockJiart  on  the  scalp  of  children ;  the  sycosis  of 
hairy  regions  such  as  the  beard,  moustache  and  nape  of  the  neck ; 
the  traumatic  pustular  dermatitis  of  the  extremities  (wrongly  called 
eczema  chroniciim  by  Unna).  It  is  this  pustule  which  provokes  the 
traumatism  of  thapsia,  croton  oil  and  oil  of  cade.  It  is  this  pustule 
which  precedes  furuncle,  at  the  orifice  of  the  follicle  occupied  by 
the  furuncle.  It  may  occur  disseminated  on  the  whole  body  in  gen- 
eralised furunculosis.  It  is  an  accessory  element  of  all  the  chronic 
eczemas  and  the  chronic  dermatites,  but  it  is  nearly  always  a  sec- 
ondary element.  From  this  lesion  are  derived  a  great  number  of 
the  pustules  of  polymorphous  acne,  all  those  of  necrotic  acne,  fur- 
uncle and  ecthyma  of  JVillaii.  Lastly  the  staphylococci  infect  the 
surface  of  all  open  dermatites  even  when  they  have  the  streptococ- 
cus for  their  primary  cause. 

Sulphur  is  the  usual  specific  treatment  for  the  staphylococcic  pus- 
tule, but  this  is  an  irritant,  and  many  dermatites,  the  microbial  ele- 
ment of  which  is  not  the  sole  cause,  do  not  tolerate  it.  In  such 
cases  emolients  and  antiphlogistics  must  be  used. 

FURUNCLE. 

Furuncle,  or  boil,  is  constituted  by  a  focus  of  epithelial  and  con- 
nective tissue  gangrene,  usually  situated  in  the  centre  of  a  follicle. 
What  is  called  the  core  of  the  boil  is  the  sphacelus,  in  the  centre  of 
which  is  the  staphylococcic  colony  which  causes  it. 


570  SUPPURATIVE    DERMATOSES. 

The  boil  develops  with  all  the  classical  inflammatory  symptoms, 
localised  to  a  single  spot,  which  is  swollen,  hot,  red  and  painful. 
In  the  furuncle  the  subjective  symptoms  are  considerable  compared 
with  the  visible  lesion.  The  pain  may  prevent  sleep,  although  the 
general  temperature  is  not  raised.  On  the  third  day  the  lesion  is 
acuminated,  and  at  its  summit  a  yellow  sphacelic  point  is  seen  bv 
transparency.  A  drop  of  pus  raises  the  skin,  which  becomes  ulcer- 
ated.   The  core  then  appears  and  takes  2  or  3  days  to  be  eliminated. 

The  painful  symptoms  diminish  after  opening;  and  the  core, 
when  eliminated,  leaves  a  cavity  which  fills  up  in  a  few  days,  while 
the  inflammation  around  it  abates.  Furuncles  often  occur  in  series, 
which  should  indicate  a  careful  examination  of  the  general  health  of 
the  patient. 

As  soon  as  the  first  symptoms  appear  the  hair  which  centres  the 
lesion  should  be  epilated,  and  after  an  hour's  interval  two  drops  of 
tincture  of  iodine  applied ;  or  a  potato  starch  poultice,  sprinkled 
with  a  few  drops  of  camphorated  alcohol,  may  be  made  hot  and 
applied  cold.  When  it  is  certain  that  the  characteristic  sphacelus 
cannot  be  avoided,  a  deep  and  wide  puncture  should  be  made  with 
the  galvano-cautery ;  this  is  painful,  but  often  aborts  the  boil,  and  in 
any  case  renders  its  evolution  less  painful.  When  the  core  is 
formed  and  separated  it  must  be  removed  without  injuring  the 
skin,  because  it  contains  the  nucleus  of  many  others. 

Moist  dressings  are  indicated  before  elimination  of  the  core;  dry 
antiseptic  dressings  afterwards.  The  so-called  antiseptic  plasters 
should  be  avoided,  as  they  are  irritating. 

N.  B. — When  the  successive  development  of  several  boils  is 
observed  they  are  seen  to  be  preceded  by  an  interval  of  3  or  4  days,, 
by  an  orificial  pustule  which  is  the  parent  inoculation  of  the  boil. 
When  these  are  reproduced  they  should  be  systematically  destroyed 
by  the  galvano-cautery. 

CARBUNCLE. 

Carbuncle  is  a  large  boil  constituted  by  the  formation  of  several 
sphacelic  nodes  side  by  side  in  a  series,  giving  rise  to  a  series  of 
contiguous  orifices  of  elimination  on  the  surface.  The  subjective 
symptoms  of  furuncle  are  multiplied  by  the  number  of  furunculous 
foci,  and  the  general  symptoms  are  proportional  to  the  size  of  the 
carbuncle. 


SUPPURATIVE    DERMATOSES.  571 

Surgical  intervention  is  required  in  these  cases,  assisted  by  a 
spray  of  boiled  water  to  cleanse  the  deeper  parts,  and  aseptic  pastes 
to  protect  the  skin.  The  strength  of  the  patient  should  be  main- 
tained. Examination  should  be  made  for  possible  glycosuria  and 
for  any  functional  organic  disorder.  The  treatment  of  carbuncle 
is   more   surgical   than   dermatological. 


FURUNCULAR    ABSCESS. 

Sometimes,  after  symptoms  analogous  to  those  of  furuncle,  an 
incision  gives  issue  to  a  few  drops  of  pus,  instead  of  the  core.  This 
is  another  mode  of  evolution  of  the  same  process,  the  microbe  having 
given  rise  to  pus  instead  of  a  sphacelus. 

Sometimes  this  process  occurs  around  a  boil  which  has  just  devel- 
oped, as  a  complication.  In  this  case  it  may  increase  the  size  and 
symptoms  and  cause  a  post-furuncular  phlegmon.  The  origin,  symp- 
toms and  treatment  are  the  same  as  for  furuncle  and  carbuncle. 


GENERALISED    FURUNCULOSIS. 

A  generalised  furunculosis  may  be  established  in  connection  witli 
diabetes,  but  also  without  apparent  connection  with  any  general 
condition.  It  may  occur  in  all  degrees ;  in  young  or  old  subjects, 
but  more  often  about  the  50th  year ;  and  may  present  from  10  to 
1000  furuncles  in  one  year.  In  this  case  it  is  continuous  and  the 
subject  is  never  free  from  boils.  The  possible  gravity  of  this  con- 
dition is  obvious,  especially  if  it  arises  in  connection  with  a  profound 
constitutional  disorder,  such  as  diabetes. 

In  all  these  cases  the  patient  should  be  carefully  examined  from 
all  points  of  view,  and  the  urine  analysed.  The  amount  of  phos- 
phates should  be  raised  if  it  is  deficient;  oxalate  of  lime  and  uric 
acid  should  be  got  rid  of  if  they  are  present ;  and  the  diet  should  be 
regulated  to  avoid  emaciation,  which  is  a  frequent  symptom. 

There  are  cases  of  generalised  furunculosis  which  do  not  appear 
to  arise  from  any  perceptible  general  disorder.  As  a  rule  general- 
ised furunculosis  lasts  from  6  to  18  months,  and  disappears  with  or 
without  relapses. 


572  SUPPURATIVE    DERMATOSES. 

DISSEMINATED    PUSTULATION. 

In  nearly  all  cases  of  furuncles,  whether  they  are  few  or  frequent, 
each  one  occurs  3  or  4  days  after  the  evolution  of  an  ostio-follicular 
pustule  in  the  same  spot.  These  disseminated  pustulations  are  fairly 
common,  especially  in  young  men  with  red  hair.  Out  of  10  pus- 
tules, one  forms  a  boil  and  the  others  abort. 

In  generalised  furunculosis  the  patients  notice  their  boils  by  the 
receding  pustules  at  the  follicular  orifice.  Xevertheless,  so  far  as 
I  am  aware,  this  preliminary  pustulation  of  generalised  furunculosis 
is  not  mentioned  in  any  book. 

The  same  general  treatment  is  indicated  as  that  mentioned  above. 
Each  pustule  should  be  destroyed  by  puncture  with  the  thermo- 
cautery if  it  is  seen  early ;  otherwise  the  hair  should  be  epilated  and 
a  drop  of  tincture  of  iodine  applied. 


PUSTULES   OF   ACNE. 

I  have  described  pustular  acne  of  the  face  and  scapulo-thoracic 
region  sufficiently  not  to  require  repetition  (pp.  15,  464).  It  is  only 
one  of  the  elements  of  acne  indurata,  acne  punctata,  and  cystic 
sebaceous  acne. 

According  to  some  authors,  the  suppuration  of  acne  is  due,  like 
acne  punctata  itself,  to  the  special  micro-bacillus  {Unria)  (p.  13)  ; 
according  to  others,  the  suppuration  is  generally  due  to  staphylo- 
coccic infection  superadded  at  the  orifice  of  a  follicle,  previously 
occupied  by  a  comedo  (Sobourand)  ;  and  when  this  infection  is 
produced  by  the  common  staphylococus  albiis.  it  produces  common 
suppurative  acne;  when  the  infection  is  that  of  the  staphylococcus 
aureus,  it  creates  the  flat,  broad,  deeply  sphacelic  pustule  of  acne 
necrotica  {impetigo-rodens  of  HiUairei-Gaucher) . 

For  the  treatment  of  acne  pustulosa  and  acne  necrotica  see  pp. 
14  and  235. 

ECTHYMA    OF    WILLAN. 

The  ecthyma  of  IVillau,  which  is  almost  special  to  young  cavalry 
soldiers,  shews  what  becomes  of  traumatic  furunculosis  in  the  over- 
worked.    The  friction  of  the  shoulder  belt  and  braces,  and  the 


SUPPURATIVE    DERMATOSES.  573 

traumatism  of  the  saddle  determine  and  increase  simple  furuncu- 
losis.  On  the  internal  surface  of  the  thighs,  the  knees  and  the  legs 
ulcerative  lesions  are  caused  by  riding.  This  is  the  ecthyma  of 
Willan.  Each  lesion  commences  by  a  furuncle,  and  the  core  after 
expulsion  leaves  a  cavity  which  enlarges  in  all  directions.  The  deep 
ulcer  is  covered  with  a  brown  crust  of  dried  blood.  When  two 
furuncles  arise  close  together  their  cavities  may  fuse,  and  the 
ecthyma  becomes  an  extensive  ulceration.  After  healing,  indelible 
cicatrices  remain,  the  largest  of  which  may  be  an  inch  and  a  half  in 
diameter. 

General  treatment  consists  in  rest  and  baths,  and  plain,  substantial 
diet;  removal  of  the  crusts  by  moist  dressings  and  applications  of 
sub-carbonate  of  iron  ointment  (i  in  40).  The  latest  furuncles 
which  appear  should  be  treated  like  ordinary  ones. 

It  is  not  known  if  this  furunculous  ecthyma  is  the  result  of  trau- 
matism only,  or  whether  a  secondary  infection  of  the  furuncle  is 
necessary  to  constitute  it. 

The  ecthyma  of  Willan  must  not  be  confounded  wath  the  ecthyma 
of  modern  authors,  who  apply  this  name  to  what  Willan  called  rupia. 

SERO-PURULENT    PHLYCTENULE. 

In  contra-distinction  to  the  staphylococcic  pustule  which  w^e  have 
just  described,  with  its  pathological  derivatives  and  its  different 
clinical  types,  must  be  placed  the  sero-purulent  phlyctenule  caused 
by  the  streptococcus.  This  may  be  called  the  strepto-phlyctcnnlc, 
in  distinction  to  the  sfaphylo-pnstnle. 

The  most  distinct  type  is  seen  on  the  fingers  around  the  nail,  as 
whitlow  (p.  376).  On  the  palmar  surface  of  the  fingers  it  forms 
the  streptococcic  bulla  (p.  370).  On  the  face  it  forms  the  impetigO' 
contagiosa  of  Tilbury  Fox.  The  lesion  assumes  in  this  region  a 
more  crusted  appearance,  because  the  horny  epidermis  is  very  thin 
and  quickly  broken,  and  hence  more  broken  than  intact  lesions  are 
seen.  The  latter  are  somewhat  scanty  and  soon  altered  beyond 
recognition. 

Impetigo  occurs  on  the  face  (p.  7)  ;  in  the  nostrils  (p.  86)  ; 
on  the  eye  it  causes  phlyctenular  keratitis  (p.  133)  It  may  cover 
the  body  with  disseminated  elements,  and  may  cause  similar  lesions 
to  those  on  the  hands  and  fingers,  on  the  feet  and  ankles. 


574  SUPPURATIVE    DERMATOSES. 

Besides  disseminated  distinct  lesions,  the  streptococcus  may  create 
regional  and  diffuse  lesions,  when  it  infects  a  skin  already  deprived 
of  its  horny  layer,  as  in  eczema ;  or  when  permanent  friction  diffuses 
it  over  the  surfaces  in  contact.  (Perleche  p.  75)  ;  retro-auricular 
intertrigo  (p.  no);  axillary  intertrigo  (p.  259);  sub-mammary 
intertrigo  (p.  493)  ;    inguinal  intertrigo  (p.  264). 

These  lesions  having  been  described  in  the  course  of  the  book, 
I  shall  only  give  here  the  general  history,  and  shall  describe  only 
three  clinical  types  which  constitute  dermatoses  capable  of  being 
generalised  on  the  whole  body. 

The  treatment  of  streptococcic  sub-corneal  lesions  is  always  the 
same.  The  phlyctenules  should  be  opened  and  the  exulcerated 
surface  cleansed  several  times  a  day  with  solutions  of  sulphate  of 
zinc  or  copper  (i  per  cent),  followed  by  dressings  of  oxide  of  zinc 
(i  in  3).  When  the  streptococcic  lesion  is  diffused  over  a  large 
surface,  the  lotions  of  sulphates  may  be  followed  by  mild  ointments 
of  oil  of  cade : — 

Oxide  of  zinc "1  "1 

Oil  of  cade r     aa     5  grammes  h        aa  3iv 

Vaseline -^  ' 

Oil   of  birch i   gramme  3j 

Lanoline 10  grammes  5J 


ECTHYMA  (RUPIA    OF    WILLAN). 

The  strepto-phlyctenule  is  a  sub-corneal  lesion,  intra-epidermic 
and  so  superficial  that  it  affects  very  little  the  corresponding  glands 
(much  less  than  the  staphylo-pustule,  even  when  small)  ;  moreover 
it  never  leaves  cicatrices. 

But  when  it  is  situated  on  dependent  regions,  the  legs,  ankles 
and  wrists,  if  neglected  it  may  persist,  raise  the  epidermis  and 
extend  under  it,  becoming  ulcerative,  and  even  leave  a  cicatrix  after 
healing.  This  is  the  rupia  of  JVillaji  and  Bateuian  which,  according 
to  these  authors,  commences  as  a  phlyctenule,  a  large  vesicle  or  a 
fiat  bulla  (strepto-phlyctenule).  This  remains  in  situ  and  becomes 
covered  with  a  thin  brown  crust,  easily  destroyed,  under  which  is 
turbid  serum.  This  process,  when  it  has  commenced  on  one  of  the 
lesions  of  impetigo,  continues  on  all  of  them,  and  causes  the  ulcero- 
•crustaceous    lesions    with    sanious    pus    found    in    vagabonds    and 


SUPPURATIVE    DERMATOSES.  575 

■cachectic  subjects,  which  we  have  described  in  the  region  of  the 
leg  (p.  296),  where  they  most  frequently  occur  at  their  maximum 
development. 

These  ulcerations  are  streptococcic,  like  the  strepto-phlyctenvile 
from  which  they  arise.  (See  p.  9  for  methods  of  culture  of  the 
streptococcus.) 

The  local  treatment  is  confined  to  sulphate  lotions  (i  per  cent)  ; 
but  the  ecthyma  of  dependent  regions  only  heals  quickly  v/hen  the 
limb  is  kept  in  the  horizontal  position.  Moist  dressings  relieve  the 
congestion  of  the  surrounding  region  of  each  ecthymatous  ulcera- 
tion. The  healing  of  the  ulcers  is  hastened,  after  they  have  been 
■cleaned,  by  sub-carbonate  of  iron  ointment   (i  -in  40). 


ACUTE  STREPTOCOCCIC   EPIDERMATITIS. 

It  is  very  probable  that  among  the  eczemas,  or  rather  among  the 
«pidermatites  with  a  tendency  to  extension  which  are  so  named,  are 
often  confounded  cc::cmatoid  microbial  cpidcrmatites.  The  follow- 
ing case  illustrates  this  point. 

A  man  aged  45,  overworked  and  rather  stout,  presents  in  the 
inguinal  folds  an  intertrigo  which  develops  in  the  form  of  a  red 
epidermatitis  in  placards  which  extend  and  fuse  together.  The 
scrotum  and  hypogastric  region  are  then  affected.  Small  red 
geographical  patches  are  formed,  which  increase  in  size.  The 
axillje.  neck,  face,  extremities  and  even  the  conjunctiva  are  affected 
in  turn.  The  whole  skin  of  the  patient,  excepting  the  palmar  and 
plantar  surfaces,  becomes  red  and  exudative:  and  all  this  takes 
place  without  any  fever.  The  eruption  lasts  for  2]/^  mo-  ths,  slowly 
fades  and  disappears,  leaving  behind  it  a  fine  floury  desquamation, 
which  remains  for  7  or  8  months,  and  gradually  disappears. 

At  all  periods  of  the  eruption,  on  all  the  commencing  red  and 
slightly  exudative  patches,  culture  and  microscopic  examination 
show  the  presence  of  streptococcus  in  considerable  quantity  and 
almost  pure.  The  same  during  the  whole  period  of  maturity  and 
healing.  After  6  months,  cultures  of  the  dry  squames  show  swarms 
of  streptococci  in  12  hours.  This  superficial  infection  ceases  after 
a  year. 

The  interpretations  of  these  facts  vary  according  to  different 
authors.     Some  regard  it  as  an  acute  streptococcic  epidermatitis ; 


576  SUPPURATIVE    DERMATOSES. 

others  as  an  infected  eczema.  The  fact  of  infection  is  certain,  but 
it  may  be  primary  or  secondary.  This  is  the  problem  which  remains 
to  be  solved. 

Treatment  consists  in  lotions  of  sulphates  (i  in  looo)   and  mild 
oil  of  cade  ointments : — 

Oil  of  cade 1  1       „.,   5; 

„    .  ,       ,    .  ^     aa     5  grammes  I      aa  .^J 

Oxide  of  zinc J  J 

Lanoline 10  grammes  5ii 

Vaseline 50  grammes  jj 


CHRONIC    STREPTOCOCCIC    EPIDERMATITIS. 

Certain  dermatites  of  the  folds  remain  chronically  exudative, 
nnpetiginous  and  streptococcic.  In  these  cases  the  skin  of  the  chron- 
ically affected  regions  is  thickened  and  constitutes  a  local  inflam- 
matory condition,  which  is  a  mixture  of  impetiginisation  and 
lichenisation.  It  is  very  difficult  to  cure,  and  may  last  for  months 
or  even  years  with  partial  remissions. 

The  same  controversial  discussion  which  we  have  mentioned  a 
few  lines  above  applies  to  this  morbid  type.  The  treatment  is  the 
same  as  in  acute  epidermatitis  of  the  same  nature. 


IMPETIGINISATION. 

Impetiginisation  is  the  assemblage  of  symptoms  of  impetigo  w'hen 
they  are  superposed  on  a  pre-existing  dermatitis.  When  the  horny 
epidermis  is  decorticated  by  scratching  (pediculosis,  scabies,  prurigo 
of  Hebra),  by  a  burn  or  by  a  traumatic  eczema,  etc.,  and  accidental 
inoculation  becomes  easy. 

The  characteristics  of  impetiginisation  are  ( i )  an  abundant 
serous  exudation  which  coagulates  in  amber  crusts:  (2)  the  exist- 
ence under  the  crust  of  a  thin  fibrinous  coagulation,  of  a  pale  lilac 
colour,  which  appears  as  if  spread  on  with  a  brush. 

The  proof  of  superficial  streptococcic  infection  is  established  by 
culture  of  the  exudation  on  bouillon-serum  (p.  9). 

The  treatment  is  that  if  impetigo,  by  lotions  and  dressings  with 
the  following: — 


SUPPURATIVE    DERMATOSES.  577 

Sulphate  of  Zinc 3  grammes     gr.  3 

Sulphate  of  Copper 2  grammes     gr.  2 

Distilled  water 500  grammes     5j 

Impetiginisation  is,  as  a  rule,  easy  to  reduce,  but  the  affection  on 
which  it  is  superposed  (eczema  of  adolescents,  prurigo  of  Hebra) 
often  persists  with  its  special  characters,  after  the  impetiginisation 
has  disappeared. 


37 


MEASLES— RUBELLA— ROSEOLAS. 


RUBEOLIFORM    ERYTHEMATA. 


Measles,    being    the    type    of   eruptions   of    this-^ 
kind  will  be   considered   before   them   .... 


Rubella,    an    exanthcmatous    fever,    much    more\ 
rare,  zvil  be  considered  next J         ^   ^ 


[-Measles     ....   p.  5/8 
.    .    .  p.  580 


Roseolas   .    .    .    .   p.  s8o 


Roseolas 
vers     . 


of     fe- 


Under  the  name  of  roseolas  are  included  every 
macular  red  eruption  having  a  tendency  to  gen- 
eralisation. These  may  be  produced  by  a  great 
number  of  causes 

There  are  first  the  roseolas  of  infectious  fevers:' 
ike  rose  spots  of  typhoid  fever;   the  rubeoliform 
rash  of  variola;  the  rubeoliform  erythema  of  diph- 
theria and  puerpural  fever,  etc 

The    great    chronic    infections,    syphilis,    leprosy' 
and    tuberculosis,   have   roseohir   eruptions,   differ- 
ing considerably  from  each  other,  which  zve  shall 
consider   separately 

/  shall  next  deal  with  the  medicamentous  ro^^-1  Medicanientous 

olas J      roseolas     .    . 

Sero-therapeutic 


p.  581 


Roseolas  of  chro- 
nic infections  .   p.  581 


.   the  sero-therapeutic  and  vaccinal  roseolas  r  1 

'  J       roseolas 


p.  583 
p.  583 


Pityriasis       rosea. 
Lichen  planus  .  p.  584 


And  I  shall  conclude  with  a  fezv  xvords  to  dif- 
ferentiate the  true  roseolas  from  surfy,  vesicular 
and  papular  eruptions  which  may  resemble  them; 
such  as  pityriasis  versicolor,  pityriasis  rosea  and 
lichen  planus 

MEASLES. 

Measles  being  the  type  of  rubeoliform  erythemas  should  be  con- 
sidered briefly  before  them. 

It  is  a  specific,  contagious,  epidemic  disease,  characterised  by  a 
catarrh  of  the  mucous  membranes,  and  a  generalised  maculo-papular 
eruption.  The  incubation  is  10  days  before  the  appearance  of  the 
symptomatic  catarrh  of  invasion,  and  14  days  before  the  eruption. 

The  invasion  is  announced  by  oculo-nasal  catarrh.  The  eye  is 
watery,  and  there  is  pus  in  the  internal  angle:  there  is  pharyngitis 
and  laryngitis  and  the  child  snuffles  and  sneezes.  Lastly  a  bronchial 
catarrh  is  developed  with  rales  and  rhonchi.  These  symptons  last 
for  3  or  4  days,  after  which  the  fever  is  established  with  rigors, 


MEASLES— RUBELLA— ROSEOLAS.  579 

thirst,  anorexia  and  more  or  less  complete  insomnia.  The  face  is 
red  and  swollen  but  so  far  without  evident  eruption.  The  mucous 
membrane  of  the  palate  is  yellowish  red,  stippled  with  a  deeper  red. 
The  gums  are  swollen  and  affected  with  catarrh  like  all  the  mucous 
membranes.  The  temperature  at  this  time  is  104°  F.  or  more,  and 
the  eruption  now  appears. 

This  begins  on  the  face,  neck  and  chest.  Its  elementary  lesion  is 
a  red  lenticular  macule,  slightly  papular,  and  disappearing  on  pres- 
sure.    The  eruption  may  be  scanty,  profuse  and  florid,  or  discrete, 


Figr.  213.     Measles.      (Jeanselme's   patient.      Photo   by   Nolrfi.) 

coherent  and  confluent.  It  occurs  on  the  upper  part  of  the  body 
on  the  first  day ;  the  trunk  and  arms  on  the  second ;  the  lower  limbs 
on  the  third;  and  on  the  4th  day  it  becomes  paler.  After  the  5th 
day  it  does  not  appear  red,  but  grey  and  iridescent.  Desquamation 
then  occurs  and  lasts  for  two  weeks:  it  is  finely  pityroid,  furfura- 
ceous,  rarely  lamellar,  and  always  discrete.  The  bronchial  catarrh 
lasts  as  long  as  the  eruption,  and  only  disappears  after  it. 

]\Ieasles  may  be  normal,  atypical,  malignant,  hyperpyretic,  or  of 
a  neurotic  form.     It  may  be  followed  by  naso-pharyngeal  catarrh 


58o  MEASLES— RUBELLA— ROSEOLAS. 

and  stridulous  laryngitis.  The  bronchitis  may  also  persist,  and 
later  on  tracheo-bronchial  tuberculous  adenopathy,  or  even  pulmon- 
ary tuberculosis  may  occur.  Divers  complications  may  arise  in  the 
course  of  measles ;  the  most  dangerous  being  broncho-pneumonia. 
Aleasles  is  often  associated  with  other  infantile  diseases,  such  as 
whooping-cough.  Complications  may  also  arise  during  convales- 
cence, among  which  may  be  mentioned  cutaneous  nodules  or  gan- 
grene, which  are  more  liable  to  occur  after  measles  than  any  other 
eruptive  iexir. 

The  treatment  of  measles  is  entirely  symptomatic,  and  the  disease 
is  usually  benign,  but  the  sequelae  are  often  less  so.  Isolation  should 
be  practised  early,  for  the  disease  is  most  contagious  in  the  catarrhal 
period  preceding  the  eruption, 

RUBELLA. 

Rubella  (German  measles)  is  an  uncommon  disease,  seasonal, 
epidemic  and  contagious,  and  characterised  by  general  adenopathy, 
pruritus    and    an   exanthem. 

The  incubation  is  from  12  to  14  days,  and  the  invasion  occurs 
in  a  few  hours,  without  previous  oculo-nasal  catarrh.  The  fever 
is  very  moderate,  from  100°  to  101°  F.  The  erythema  has  been 
described  very  differently,  but  in  the  cases  which  I  have  seen  it 
resembled  that  of  measles,  but  with  punctiform  macules.  There  is 
nearly  always  an  intense  pruritus  which  precedes  the  eruption. 
Multiple  adenopathy  on  the  nape  of  the  neck  and  axillae  is  very  evi- 
dent and  attracts  the  patient's  attention.  The  eruption  lasts  for 
three  days  and  disappears  without  complications,  and  without 
desquamation.  Rubella  is  much  less  contagious  than  measles,  and 
requires  no  treatment. 

TYPHOID    ROSEOLA. 

On  the  7th  day  of  typhoid  fever  lenticular  rose  spots  appear 
consisting  of  slightly  papular  macules,  which  disappear  under  pres- 
sure and  reappear  quickly.  They  are  generally  few  in  number,  and 
are  scattered  over  the  abdomen,  flanks  and  chest.  Occasionally  they 
are  sufficiently  abundant  to  simulate  an  exanthematous  fever.  The 
eruption  rarely  lasts  more  than  7  or  8  days,  and  is  complete  in  3 
days.  It  has  been  stated  that  florid  typhoid  roseola  signifies  benign 
typhoid, 


MEASLES— RUBELLA— ROSEOLAS.  581 

DIPHTHERITIC   ROSEOLA. 

Besides  the  eruptions  due  to  sero-therapy,  diphtheria,  in  12  per 
cent  of  cases,  gives  rise  to  an  early  or  late  eruption,  having  the 
lenticular  maculo-papular  characters  of  measles,  but  the  topo- 
graphical distribution  of  erythema  multiforme,  usually  on  the  wrists 
and  ankles. 

This  appears  to  be  one  of  the  innumerable  secondary  poly- 
morphous erythemas  which  may  arise  in  the  course  of  all  infec- 
tions. The  eruption  causes  a  rise  of  temperature  of  one  degree  for 
several  hours.  It  lasts  several  days,  like  polymorphous  erythema, 
and  is  often  developed  in  crops.  It  disappears  slowly,  and  requires 
no  treatment. 

RUBEOLIFOKM  ERYTHEMA  IN  PUERPURAL  FEVER. 

I  have  seen  a  generalised  rubeoliform  eruption  at  the  terminal 
period  of  a  fatal  case  of  puerpural  fever.  The  macules  were  quite 
flat,  not  papular,  and  as  large  as  the  end  of  the  finger.  After  the 
3rd  day  the  eruption  produced  a  desquamation  with  large  squames, 
all  over  the  body.  The  eruption  appeared  about  the  30th  day  of 
the  disease,  and  five  days  before  death. 

SYPHILITIC   ROSEOLA. 

Syphilitic  roseola  marks  the  commencement  of  the  secondary 
phenomena  and  is  one  of  the  most  definite  lesions  in  the  cyclic 
evolution  of  the  disease.  It  is  seen  about  80  days  after  inoculation. 
It  may  be  very  marked,  or  only  slightly  visible;  very  discrete  or 
confluent;  the  macules  may  be  very  pale  or  very  red.  Each  one  is 
smaller  than  the  end  of  the  little  finger;  they  are  very  equally  dis- 
tributed, and  more  apparent  on  the  flanks,  abdomen,  shoulders  and 
flexor  surfaces  of  the  limbs.  The  skin  has  a  mottled  appearance. 
This  eruption  may  be  accompanied  in  the  first  few  days  by  slight 
general  symptoms  of  febricula;  but  these  are  more  often  absent. 
The  syphilitic  roseola  may  last  for  3  weeks  or  more,  or  may  dis- 
appear in  a  few  days. 

The  diagnosis  is  always  assisted  by  the  coexistence  of  the  indura- 
tion of  the  chancre  and  the  satellite  ganglion  or  pleiades,  and  gen- 


S82  MEASLES— RUBELLA— ROSEOLAS. 

eral  polyadenitis.  At  the  end  of  roseola  mucous  patches  may 
develop.  The  local  treatment  of  the  roseola  is  nil.  Syphilitic  treat- 
ment, if  not  already  begun,  should  be  instituted  without  delay. 

Under  the  name  of  recurrent  roseola  an  eruption  has  been 
described,  consisting  of  rose  macules  much  more  rubeoliform  than 
those  of  secondary  roseola.  These  are  scanty,  discrete,  scattered  on 
the  flanks,  and  often  limited  to  the  trunk.  These  spots  persist  for 
a  long  time  and  their  true  nature,  origin,  and  signification  are 
doubtful. 

LEPROUS    ROSEOLA. 

The  name  of  leprous  roseola  is  given  to  the  first  eruption  which 
characterises  leprosy,  although  this  eruption  may  be  preceded  by 
numerous  premonitory  symptoms  (p.  655). 

Leprous  roseola  is  composed  of  erythematous  pigmentary  ma- 
cules, the  size  of  the  end  of  the  finger,  or  larger.  It  is  more  or 
less  discrete  or  abundant,  and  the  macules  may  be  pale  or  florid: 
they  are  slightly  raised  on  the  skin.  The  eruption  occurs  in  multiple 
subinvolutive  crops,  so  that  elements  of  different  ages  and  tints 
coexist  side  by  side.  It  may  be  accompanied  by  marked  febrile 
symptoms.  In  certain  cases  the  macules,  from  the  first,  are  the 
seat  of  disorders  of  sensation,  which  become  more  and  more 
pronounced. 

Leprous  roseola  is  not  a  transitory  lesion  like  syphilitic  roseola, 
and  the  macules  may  remain  for  several  months.  They  may  enlarge 
and  become  achromic  and  change  in  situ  into  tubercular  or  atrophic 
lesions.  I  shall  deal  with  the  evolution  of  leprosy  in  general  later 
on  (p.  655)  and  shall  not  dwell  on  it  any  more  here. 

TUBERCULOUS  ROSEOLA. 

It  would  be  incorrect  to  apply  this  term  to  the  generalised  erup- 
tions of  the  tuberculides  (p.  ).  These  are  not  rubeoliform,  but 
papulo-tuberculous,  with  necrotic  and  cicatricial  evolution  (acne 
cachccticorum).  It  is  an  eruption  which  seems  to  have  the  same 
nosological  signification  as  the  roseolas  of  syphilis  and  leprosy,  but 
which  has  neither  the  same  objective  form,  nor  the  same  evolution. 

These  eruptions  will  not  be  considered  further  in  this  place,  as 
they  have  been  studied  elsewhere  (pp.  331,  338,  556). 


MEASLES— RUBELLA— ROSEOLAS.  583 

MEDICAMENTOUS  ROSEOLAS. 

These  are  very  common,  seldom  pure  as  an  objective  type,  but 
more  often  mixtures  of  erythematous,  urticarial  and  scarlatiniform 
lesions,  etc.  Nevertheless  there  are  some  which,  objectively,  are 
only  macular,  of  slightly  papular  roseolas ;  incomplete,  discrete  or 
localised. 

Antipyrine.  Antipyrine,  several  hours  after  its  ingestion,  may 
determine  a  papular  roseola.  The  conjunctiva  and  buccal  mucous 
membrane  are  also  usually  affected.  Besides  the  roseola  there  are 
often  seen  other  more  scanty  lesions  in  the  form  of  a  rosette,  slightly 
papular  and  of  longer  duration  than  the  roseola. 

Balsams  administered  in  the  course  of  gonorrhoea  often  give  rise 
to  a  well  known  roseola,  which  begins  on  the  extensor  surfaces  of 
the  large  joints  and  may  extend  to  a  variable  extent.  It  quickly 
fades  and  disappears,  often  when  the  medicament  is  continued. 

Bromoform,  the  vapour  of  bromine,  the  internal  administration  of 
bromides,  hemlock  and  cicutine  have  also  given  rise  to  medicamen- 
tous  roseolas  of  a  type  similar  to  the  preceding.  They  disappear: 
after  suppression  of  the  cause. 

The  antitoxin  serums  of  diphtheria,  tetanus,  plague  and  anti- 
venomous  serum,  etc.,  cause  a  rubeoliform  erythema,  which  appears 
on  the  1 2th  or  13th  day  after  injection.  It  preponderates  on  the 
face,  neck  and  limbs,  and  is  frequently  urticarial  and  pruriginous 
(p.  534).  All  these  erythemas  are  similar  and  are  accompanied  by 
variable  general  phenomena,  which  may  in  themselves  be  distress- 
ing:— polyarthralgia,  vomiting  and  diarrhoea,  anuria,  albuminuria. 
They  disappear  in  48  hours  without  treatment  and  are  never  severe. 
The  slowness  of  convalescence  has  been  incorrectly  attributed  to 
them. 

VACCINAL  ROSEOLA. 

This  is  essentially  benign  and  appears  from  the  4th  to  the  nth 
day  after  vaccination,  without  fever.  It  lasts  3  to  5  days  and 
disappears  in  2  days.  It  has  to  be  looked  for  to  be  noticed,  as  it 
causes  no  functional  symptoms. 

PITYRIASIS    ROSEA    OF    GIBERT. 

Two  generalised  dermatoses  may  be  mistaken  by  novices  for 
roseola;  pityriasis  rosea  and  lichen  planus.     Pityriasis  rosea  com- 


584  MEASLES— RUBELLA— ROSEOLAS. 

mences  by  a  large,  solitary,  trichophytoid  lesion,  situated  on  the 
trunk  or  the  root  of  the  limbs.  After  3  to  5  weeks  a  rapid  eruption 
of  rose-violet,  oval  spots  appears,  at  first  the  size  of  a  pea,  after- 
wards as  large  as  a  sixpence.  When  they  have  attained  this  size, 
their  surface  is  iridescent,  and  their  periphery  marked  by  a  pityroid 
collarette.  This  sudden  eruption  covers  the  trunk,  the  limbs  and 
the  neck,  but  avoids  the  face  and  usually  the  extremities.  It  lasts 
two  months  and  then  fades  (p.  521). 

LICHEN    PLANUS    OF    ERASMUS    WILSON. 

The  eruption  of  lichen  planus  should  still  less  be  mistaken  for  a 
roseola.  It  is  composed  of  distinctly  raised  papules  which  may 
occur  anywhere,  but  the  eruption  is  slow,  and  even  when  florid, 
does  not  appear  rapidly.  The  characteristic  elements  are  in  the 
form  of  an  archipelago,  with  a  large  central  element  surrounded  by 
small  ones. 

The  papules  have  a  lilac  colour  and  are  distinct  and  irregular ;  the 
larger  ones  being  marked  with  a  fine  white  reticulum.  The  eruption 
is  pruriginous  and  develops  slowly  without  general  symptoms 
during  several  months  with  a  period  of  increase,  a  stationary  period, 
and  a  period  of  decrease. 

There  is  nothing  in  this  which  resembles  an  exanthem  or  a 
roseola.  One  could  hardly  say  this  of  a  violet  eruption  developed 
on  a  clear  lilac  base  covering  the  entire  body ;  but  the  first  question 
shews  the  slowness  of  evolution  of  the  disease,  and  the  first  objec- 
tive examination  discovers  the  papules  (p.  553). 


SCARLATINA. 

SCARLATINIFORM    ERUPTIONS. 

Scarlatina  is  the  type  of  a  series  of  dematological\^ 
affections   which   are   more   or   less  scarlatiniformS    '^^^  ^tina      ...   p.  58= 

Variola  at  its  period  of  invasion  may  present 
divers  eruptions,  among  zvhich  scar  latini  form 
rashes  are  most  frequent 

More  properly  dermatological  is  the  recurrent 
desquamative  erythema,  the  name  of  zvhich  in- 
dicates its  chief  characters 


Scarlatinif  or  m 
rash  of  variola  p.  586 

Scarlatinif  or  m 
erythema   ...   p.  587 


And   the  more  or  less  scarlatiniform   erythemas     „      .  ,  _„ 

,    ,       j.rr         ^    •   ^      •     ,•  ^loxic  erythemas  p.  588 

caused   by   different   intoxications J 

The  most  important  is  that  of  mercurial  intoxica-'\ 
tion,  which   presents   the   characters   of  .fcar/ahm- [-Hydrargyrism     .   p.  588 
form   erythema   very   exactly 


SCARLATINA. 

Scarlatina  is  the  prototype  of  a  series  of  dermatological  scarlati- 
niform erythemas.  It  is  therefore  illogical  to  describe  the  latter 
without  the  former. 

Scarlatina  is  an  acute,  epidemic,  contagious  disease  characterised 
by  a  special  exanthem  and  angina.  The  incubation  may  be  from  7 
hours  to  5  days.  The  invasion  is  rapid.  The  onset  of  scarlatina 
is  always  sudden  and  accompanied  by  malaise,  pain  and  rigors,  with 
a  temperature  of  102°  to  104°  F.  Sometimes  there  is  vomiting  and 
always  dysphagia  on  account  of  the  angina,  which  is  seldom  absent. 
The  angina  consists  in  total  pharyngitis ;  the  throat  is  scarlet ;  the 
tonsils  are  very  red  and  often  afifected  with  follicular  tonsillitis;  the 
soft  palate  is  stippled  with  red.  The  sub-maxillary  glands  are 
enlarged. 

The  eruption  begins  in  the  folds,  the  head  being  little  affected,  or 
not  at  all.  It  consists  in  9  scarlet  red  erythema,  finely  punctated 
with  violet  red  points.  The  eruption  may  be  more  or  less  prurigi- 
nous ;  it  may  be  total  or  discrete.  From  the  3rd  to  the  5th  day  the 
tongue  desquamates  from  the  tip  towards  the  root,  and  becomes 
shiny,  bright  red,  and  covered  with  red  projecting  papules.     The 


S86  SCARLATINIFORM  ERUPTIONS 

temperature  may  remain  high  for  several  days,  with  a  rapid  and 
full  pulse,  and  continued  general  symptoms.  After  5  to  7  days' 
gradual  defervescence  occurs,  and  the  eruption  fades  little  by  little. 

Ten  days  after  the  eruption,  desquamation  begins  in  the  folds  of 
flexion.  The  horny  epidermis  becomes  dry,  hard  and  wrinkled  and 
is  detached  as  floury  powder  in  the  hairy  regions ;  as  scales  in 
regions  where  the  skin  is  thin;  as  flakes  on  the  hands  and  feet. 
The  nails  are  never  shed.  Desquamation  terminates  on  the  30th 
or  40th  day. 

I  shall  only  mention  by  the  way  the  atypical  scarlatinas;  without 
exanthem,  hypertoxic  and  malignant,  apyretic,  hyperpyrexia!,  ataxo- 
adynamic,  haemorrhagic  and  recurrent. 

The  angina  at  first  is  rarely  diphtheritic,  but  may  be  so,  and  in 
doubtful  cases  sero-therapy  should  be  tried.  The  chief  complica- 
tions of  scarlatina  aflfect  the  serous  membranes ;  pericarditis,  endo- 
carditis, pleurisy  and  rheumatism.  It  is  often  complicated  by  late 
diphtheritic  angina  and  nephritis  (streptococcic)  with  benign  or 
severe  albuminuria. 

Treatment  is  not  specific  but  symptomatic.  The  mouth  and  throat 
should  be  disinfected  with  oxygenated  water.  The  skin  should  be 
covered  with  an  inert  fatty  ointment  to  prevent  dispersion  of  the 
squames,  which  are  the  cause  of  contagion.  The  disease  is  less 
contagious  than  measles,  but  the  patient  remains  contagious  during 
the  whole  disease  and  possibly  during  convalescence.  Scarlatina 
confers  absolute  immunitv  for  life. 


SCARLATINIFORM     RASH. 

During  the  period  of  incubation  of  variola,  which  may  be  2  to  4 
days,  there  often  appears  an  outbreak  of  variable  objective  symp- 
toms, sometimes  roseolar,  sometimes  scarlatiniform,  or  even  pur- 
puric (haemorrhagic  or  black  smallpox).  This  premonitory  erup- 
tion occurs  especially  in  the  flexures  of  the  joints,  but  may  invade 
the  whole  surface  of  the  body.  Sometimes  the  variolous  eruption 
occurs  at  intervals  during  the  presence  of  this  rash.  The  rash  is 
generally  incomplete  and  disappears  quickly. 

The  diagnosis  is  made  by  the  subjective  and  general  symptoms 
being  out  of  proportion  to  the  eruption.    The  temperature  iiKiy  be 


SCARLATINIFORM   ERUPTIONS  587 

above  104°  F.  and  the  patient  suffers  from  intolerable  pains  in  the 
back  and  headache ;  thirst,  anorexia,  rigors,  etc. 

The   diagnosis    is   confirmed   by   the   appearance   of   umbilicated 
vesicles  on  the  forehead  and  face. 


RECURRENT    DESQUAMATIVE  SCARLATINIFORM 
ERYTHEMA, 

Recurrent  scarlatiniform  erythema,  in  its  normal  type,  is  a  scarla- 
tina without  angina.  It  begins  with  rigors  and  elevation  of  the 
temperature  (100°  to  104°  F.,  rapid  pulse,  shallow  respiration,  pain 
in  the  back,  headache  and  insomnia.  The  eruption  is  rapid,  and 
may  be  developed  in  a  few  hours,  or  not  for  three  days.  It  begins, 
either  by  numerous  macules  which  enlarge,  or  in  large  patches 
which  become  confluent.  These  appear  on  the  chest,  shoulders, 
arms  and  inner  surface  of  the  thighs.  Some  regions,  sometimes  the 
head,  are  exempt.  The  red  colour  disappears  under  pressure  by  a 
glass  slide  and  the  skin  appears  yellow. 

Desquamation  commences  3  or  4  days  after  the  eruption  or  before 
its  disappearance  (Besnier).  It  is  dry  and  very  abundant,  and  is 
complete  in  3  weeks.  The  bed  contains  handfuls  of  lamellar 
squames ;  branny  or  furfuraceous  from  the  hairy  regions,  and  in 
large  patches  from  the  palms  and  soles.  Like  all  the  red  and 
exfoliating  dermatites  the  desquamation  is  accompanied  from  the 
first  by  a  perpetual  sensation  of  cold. 

A  number  of  visceral  infectious  manifestations  have  been  reported 
in  the  course  of  scarlatiniform  erythema,  from  its  commencement 
to  its  decline ;  endocarditis,  pericarditis,  sub-acute  polyarthritis, 
transient  or  permanent  albuminuria,  suppurative  otitis,  herpes,  etc. 

The  nails  are  marked  with  a  deep  transverse  furrow.  The  hair 
falls  immediately  when  the  erythema  occurs  on  the  scalp,  80  days 
later  in  the  contrary  case. 

This  disease  is  very  rare,  and  is  recurrent.  The  recurrences  are 
usually  less  severe  than  the  first  attack  and  diminish  gradually  in 
severity.  They  may  occur  after  months  or  years,  irregularly,  and 
eventually  die  out. 

Recurrent  scarlatiniform  erythema  has  been  confounded  with 
acute  erythematous  hydrargyrism.  They  are  similar  eruptions,  but 
of  essentially  different  causes.    The  cause  of  scarlatiniform  erythema 


S88  SCARLATINIFORM    ERUPTIONS 

appears  to  be  infectious,  but  remains  hypothetical.  All  treatment 
is  symptomatic.  However,  the  action  of  collargol  (soluble  silver) 
should  be  tried,  as  in  all  acute  septicaemias,  but  without  anticipating 
too  successful  results. 

TOXIC    SCARLATINIFORM    ERYTHEMA. 

Many  medicaments  may  determine  extensive  scarlatiniform 
erythemas.  For  instance,  digitalis  and  its  derivatives  may  provoke 
an  erythema  followed  by  desquamation  in  large  horny  epidermic 
patches,  and  even  loss  of  the  hair  and  nails.  Also  ipecacuanha, 
emetine,  quini)ie,  morphine  and  daturine.  The  antitoxic  serums  may 
also  cause  transient  scarlatiniform  erythema  with  general  symptoms 
(p.  ).  But  the  best  type  is  furnished  by  hydrargyrism,  in 
mercurial  poisoning. 

Certain  subjects  cannot  absorb  any  preparation  of  mercury  in  any 
form,  either  under  the  skin,  or  by  the  intestine,  or  even  by  cutaneous 
application,  without  more  or  less  cutaneous  reaction,  which  is 
always  out  of  proportion  to  the  dose  of  the  medicament  w^hich 
provokes  it.  Other  subjects  only  suffer  from  these  phenomena  with 
certain  mercurial  preparations.  These  scarlatiniform  mercurial 
erythemas  may  not  be  accompanied  by  any  mercurial  stomatitis. 
They  result,  not  from  total  intoxication  of  the  subject,  but  from 
cutaneous  intoxication. 

Mercurial  scarlatiniform  erythema  may  be  benign,  moderate  or 
severe.  It  may  end  fatally  if  its  cause  is  not  recognised.  Every 
acute  scarlatiniform  erythema,  even  recurrent,  and  every  exfoliating 
erythrodermia,  even  chronic,  should  SLiggest  cutaneous  hydrargy- 
rism. The  symptomatology  of  acute  cutaneous  hydrargyrism  is  so 
similar  to  that  of  recurrent  scarlatiniform  erythema  that  certain 
authors  doubt  the  existence  of  the  latter. 

Treatment  consists  in  immediate  suppression  of  the  cause,  which 
is  often  only  discovered  after  careful  enquiry. 


ERYSIPELAS    AND    ERYTHRODERMIA. 


Erysipelas  is  still  a  morbid  type  with  which' 
many  dermatological  lesions,  erythrodermias,  are 
daily  compared.  We  shall  commence  with  a 
resume  of  its  symptoms 

After   this  we  shall  consider   the   chronic,  gen-' 
eralised,  exfoliating  erythrodermias,  distinguishing 
among  the  clinical  types  so  named,  the  only  ones 
which  present  a  true  clinical  autonomy 


-  Erysipelas 


P-SSg 


Generalised  ex- 
foliating e  r  y- 
throdermias  .  .  p,  590 


ERYSIPELAS. 


Erysipelas  may  occur  in  all  regions.  We  have  already  described 
three  different  types :  erysipelas  of  the  face,  umbilical  erysipelas  of 
the  newly  born  and  vaccinal  erysipelas. 

It  is  always  accompanied  by  general  phenomena;  rigors,  nausea, 
and  sudden  elevation  of  the  temperature.  In  a  few  hours  the  objec- 
tive symptoms  appear  around  the  point  of  inoculation ;  a  red  patch, 
hot,  tense,  swollen  and  painful,  and  limited  by  a  characteristic  raised 
margin. 

Erysipelas  may  be  limited  from  the  first,  or  progressive,  or  ambu- 
latory. In  the  latter  case  it  recedes  at  one  point,  while  extending 
at  another.  The  fever  is  continuous,  with  evening  rises.  There 
may  be  pain  in  the  back,  headache,  and  in  the  adtjlt  even  delirium. 
Between  the  5th  and  nth  day  the  temperature  falls  almost  suddenly 
and  the  affection  is  cured. 

Contrary  to  the  old  clinical  dogma,  erysipelas  may  suppurate,  and 
be  complicated  with  gangrene  (spontaneous  gangrene  p.  428).  All 
the  complications  of  infectious  diseases  may  be  observed  during  its 
course  and  decline,  but  they  are  rare.  Recurrent  erysipelas  is  not 
uncommon,  especially  on  the  face,  and  at  other  places  around 
chronically  open  lesions  (Elephantiasis  nostras,  p.  306).  The  prog- 
nosis is  generally  benign  in  the  adult,  but  grave  in  the  newly  born. 

Antistreptococcal  serum  has  only  given  doubtful  results  and  is 
practically  little  used.  Treatment  is  symptomatic,  with  moist 
dressings  locally. 


590  ERYSIPELAS    AND    ERYTHRODERMIA. 

Erysipelas  has  often  been  compared  to  the  chief  red  dermatites, 
which  many  authors  regard  as  chronic  infectious  dermatites  of 
analogous  pathology.  But  this  comparison  is  hypothetical,  and  it  is 
for  experimental  research  to  determine  the  nature  of  er>1;hrodermias, 
as  it  has  determined  that  of  erysipelas. 


CHRONIC    GENERALISED    EXFOLIATING    ERYTHRO- 
DERMIAS    (PITYRIASIS    RUBRA    OF    HEBRA). 

(i)  Certain  diseases,  such  as  pityriasis  rubra  pilaris,  mycosis 
fiingoidcs  and  pernicious  lymphodermia  of  Kaposi,  may  begin  by  a 
phase  of  erythrodermia ;  but  this  is  simply  a  variety  of  onset  of 
these  different  diseases,  and  has  nothing  in  common  with  the 
generalised  exfoliating  erythrodermia  of  which  I  am  speaking. 

(2)  Similar  erythrodermic  crises  may  arise  in  the  course  of  lichen 
planus,  eczema,  psoriasis  with  fatty  squames,  pityriasis  rubra  pilaris, 
etc.  These  crises  sometimes  appear  under  the  influence  of  external 
applications  (traumatic  eruptions),  or  of  external  medication  (mer- 
cury and  arsenic)  ;  but  it  is  possible  that  a  true  generalised  exfoliat- 
ing erythrodermia  may  complicate  these  divers  processes  as  an 
episode  (Besnier). 

(3)  This  view  is  more  tenable,  especially  as  certain  dermatoses, 
such  as  those  which  we  have  just  named,  may  terminate  by  a 
secondary,  but  authentic,  generalised  exfoliating  erythrodermia. 

(4)  Lastly,  there  exists  a  generalised  primary  exfoliative  ery- 
throdermia, of  slow  evolution  and  always  grave,  often  fatal;  char- 
acterised objectively  by  intense  redness  of  the  skin  over  the  whole 
body,  accompanied  by  continual  lamellar  exfoliation  of  the  epider- 
mis, profound  changes,  and  falling  of  the  hair  and  nails.  This 
generalised  dermatitis  is  accompanied  by  general  symptoms;  fever 
of  the  hectic  type,  perpetual  sensation  of  cold  and  thirst,  and  pro- 
gressive weakness,  ending  in  cachexia  and  marasmus,  or  terminat- 
ing by  some  intercurrent  affection. 

At  other  times,  after  8  to  12  months,  under  the  influence  of  well 
applied  treatment,  the  general  condition  may  gradually  improve,  and 
the  patient  may  recover  almost  perfect  health,  or  return  to  the 
condition  of  eczema  or  simple  psoriasis  which  preceded  the  disease. 


ERYSIPELAS   AND    ERYTHRODERMIA. 


591 


Ftgr.  214.     Pityriasis  rubra  of  Hebra. 
(RadcHfCe  Crocker's  patient.     Atlas  of  Diseases  of  the  Skin.) 


592  ERYSIPELAS    AND    ERYTHRODERMIA. 

The  cause  and  mechanism  of  this  affection  are  unknown.  It  has 
been  classed  hypothetically  as  an  infectious  disease  of  the  skin  and 
compared  to  chronic  erysipelas.^ 

In  spite  of  certain  differences  in  symptomatology  and  evolution, 
I  think  that  this  dermatological  type  is  the  same  as  that  known  in 
Germany  under  the  name  of  pityriasis  rubra  of  Hebra,  which  may 
itself  be  primary  or  secondary  to  eczema  and  psoriasis  (especially 
with  fatty  squames)  and  evolve  after  several  months  either  towards 
cure  or  death. 

Local  treatment  should  be  as  careful  as  possible.  Applications  of 
fresh  oil  of  almonds,  linimentum  calcis,  zinc  creams,  etc.,  are  the 
best  tolerated.  In  my  opinion  the  treatment  rests  entirely  in  super- 
alimentation. Every  patient  who  can  be  made  to  gain  weight  will 
be  cured  in  a  few  months ;  but  this  super-alimentation  must  be 
progressive  and  continuous.  It  should  be  carried  out  in  the  same 
way  as  in  curable  tuberculosis.  The  articles  of  choice  are  eggs, 
milk,  starchy  foods,  fats  and  sugars ;  but  any  diet  is  good  so  long 
as  the  patient  desires  it  or  tolerates  it.  I  cannot  say  more  than  this, 
for  no  one  has  treated  enough  of  these  cases  to  conclude  definitely 
concerning  their  therapeutics,  and  this  remains  the  whole  treatment 
which  is  useful  in  generalised  exfoliating  erythrodermias.  It  may 
not  be  always  possible,  but  it  is  surprising  to  see  in  how  many 
cases  it  succeeds. 

1  Certain  symptoms  of  generalised  exfoliating  erythrodermias  are  most  in- 
teresting from  the  point  of  view  of  physiology.  I  wish  to  point  out  especially 
that  a  patient  being  in  bed  and  covered  with  bed-clothes,  the  latter  (especially 
if  the  temperature  of  the  room  is  low)  become  covered  with  a  fine  spray,  the 
droplets  of  which  are  suspended  on  each  hair  of  the  fabric ;  and  this  spray 
corresponds  exactly  to  the  body  of  the  patient.  This  phenomenon  explains 
two  constant  symptons  of  the  disease  ;  the  thirst,  by  the  great  loss  of  water 
exhaled  through  the  diseased  horny  epidermis,  the  functions  of  which  are 
suspended;  arid  the  cold  by  loss  of  heat  caused  by  perpetual  evaporation. 


PURPURAS. 
PURPURIC    ERUPTIONS. 

Purpura  has  two  objective  symptoms,  the  purpuric  macule  or 
petechia  which  does  not  disappear  under  glass-pressure,  because  it 
corresponds  to  an  effusion  of  blood  by  vascular  rupture;  and  the 
contusiform  spot  or  ecchymosis. 

Hcemophilia    is    consanguineous    and    hereditary^ 
and  may  shczv  these  tzvo  symptoms  in  a  chronic  L Haemophilia     .    .   p.  593 
state,    the   purpuric   macule   and   ecchymosis  ... 

Toxic  purpuras,  ab  ingesfis,  are  very  rare  and^  t-      •  .-„. 

,  ,.  ,  ,  ,  .    ^  Toxic  purpuras  .  p.  594 

only  present  the  petechia  and  not  the  ecchymosis j 

The  rashes  of  eruptive  fevers  are  purpuriform 
rather  than  purpuric^  but  may  present  true  pur- 
puric   macules 

/  shall  mention  in  this  chapter  the  characters!  Purpuric  exan- 
which  constitute  the  fatal  hcemorrhagic  form  of  the  L  thematous  fe- 
diifcrcnt    eruptive    fevers I      vers p.  594 

.    .    .  and   the  purpuric  appearance  assumed  by^ 
the  skin  when  malignant  pustule  gives  rise  to  fatal  I  Charbon    ....   p.  595 
septicaemia 1 

The  true  purpuras  may  be  described  under  ^/zr^^l  Rheumatic  pur- 
forms.     The  first  is  benign  rheumatic  purpura   .    .  J      pura p.  596 

The  second  is  Werlhoff's  disease  zvith  profuse^Werlhofi's  dis- 
hccmorrhages  and  numerous  ecchymoses J      ease p.  596 

The  third  is  acute  febrile  purpura,  which  may 
have  different  degrees  of  acuteness  and  even  termi- 
nate in  death  


-Purpuric  rash  .    .    p.  594 


Acute     febrile 
purpura     ...  p.  597 


Besides  the  acute  purpuras  there  are  chronic  pur- 
puras, the  evolution  and  recurrences  of  which  are 


connected  with  divers  organic  disorders,  and  pre-  .     of     decay      and 


sent   the  prognosis   of  the  affection   of   the   heart, 
liver,  kidney,  etc.,  on  zvhich  they  depend 


Chronic    purpuras 


cachexia    ...  p. S98 


HAEMOPHILIA. 

By  the  name  haemophilia  is  designated  a  rare  hereditary  and 
consanguineous  tendency  to  fragility  of  the  blood  vessels,  and  spon- 
taneous haemorrhages  which  are  arrested  with  difficulty.  In  these 
conditions  every  wound  is  serious,  even  the  extraction  of  a  tooth 

38  .-        .  . 


594  PURPURAS. 

may  cause  haemorrhage  which  is  difficult  to  stop.  Every  injury  to 
the  skin  causes  a  sub-cutaneous  haemorrhage  and  the  body  seems 
always  to  have  been  beaten  with  blows.  This  condition  is  beyond 
the  resources  of  therapeutics. 

TOXIC   PURPURAS. 

In  certain  subjects  the  balsams,  antipyrine,  quinine  and  the 
iodides,  which  may  cause  rubeoliform  and  scarlatiniform  eruptions, 
may  also  determine  true  purpuric  spots,  not  effaced  by  glass- 
pressure.  This  fact  is  rare,  but  should  be  known.  Erythema 
occurring  on  the  12th  day  after  sero-therapy  may  be  accompanied 
by  characteristic  purpuric  patches.  All  these  purpuras  are  benign 
and  disappear  in  a  few  days  after  the  suppression  of  the  cause. 

PURPURIC    RASHES. 

The  rashes  of  eruptive  fevers  are  generally  scarlatiniform  ery- 
themas, and  it  is  exceptional  to  see  them  purpuric.  However,  pur- 
puric spots  may  be  disseminated  on  the  surface  of  a  generalised 
erythema.  This  appearance  becomes  serious  when  the  eruption  is 
accompanied  by  high  temperature  (vide  the  next  article). 

PURPURIC  EXANTHEMATOUS  FEVERS. 

There  is  a  hgemorrhagic  form  in  all  the  eruptive  fevers;  measles, 
scarlatina,  variola.  Sporadic  cases  are  rare.  Cases  are  usually 
fairly  numerous  in  the  course  of  a  severe  epidemic.  Whatever  the 
fever  concerned  (generally  scarlatina  or  variola),  the  patient  is 
purple  from  head  to  foot ;  the  general  condition  is  most  grave,  ataxo- 
adynamic  or  comatose,  and  the  temperature  nearly  106°  F.  The 
eruption  has  been  sudden,  but  no  information  can  be  obtained  from 
the  patient.  By  searching  on  the  forehead,  temples  and  lips,  a 
simple,  typical,  umbilicated  pustule  of  variola  may  be  found.  The 
diagnosis  of  ha^morrhagic  variola  is  then  established.  This  diag- 
nosis being  a  sentence  of  death,  no  means  of  confirming  it  should 
be  neglected ;  by  the  temperature  and  corroborative  evidence, 
especially  when  no  eruptive  element  is  still  present  to  absolutely 
certify  the  nature  of  the  disease. 


PURPURAS. 
MALIGNANT    PUSTULE     OR    CHARBON. 


595 


When  malignant  pustule  (p.  347)  pursues  a  fatal  course,  the 
disease  presents  an  assemblage  of  symptoms  similar  to  the  preced- 
ing.    If  the  pustule  is  situated  on  the  face,  cheek  or  eyelid,  these 

regions  are  covered  with 
yellow  fluent  sloughs ; 
the  head  is  enormously 
s  w  ol  1  e  n  and  blackish 
purple.  The  skin  pre- 
sents here  and  there  soft, 
reddish  phlyctenules, 
and  fresh  ulceratioris- 
arise  under  each  of 
them.  The  half  of  the 
body  corresponding  to 
the  situation  of  the  ini- 
tial puncture  (in  the 
case  which  I  am  de- 
scribing, the  upper  half 
of  the  body)  is  of  the 
same  blackish  purple  as 
the  head.  This  purple 
cedema  stops  at  the  level 
of  an  oedematous  swell- 
ing, which  seems  tight- 
ened wath  string.  The 
skin  under  n  e  a  t  h  is 
healthy  and  appears 
normal.  The  swelling 
advances  hourly,  dimin- 
i  s  h  i  n  g  the  remaining 
healthy  surface.  The 
temperature  is  over  106° 
F.  The  patient  becomes 
comatose  and  death  fol- 
lows about  3  days  after 
the  appearance  of  the 
Fig.  215.    Purpura  of  the  thigh,    Laii-  iirst     grave     general 

ler's     patient.       St.     I.ouis     Hosp.     Mu-  cvmntnmc 

seum.       No.     1068.)  SymptOmS. 


596  PURPURAS. 

RHEUMATIC    PURPURA. 

Several  days  after  an  apparently  slight  infection  accompanied  by 
angina  and  pains  in  the  back  and  joints,  there  appears  on  the  body, 
but  especially  on  the  limbs,  a  series  of  purpuric  macules  which  are 
not  effaced  by  glass-pressure.  These  spots  last  for  5  to  15  days 
and  generally  disappear  without  leaving  any  trace.  Sometimes  there 
are  relapses  and  nev/  spots  appear.  This  condition  may  be  pro- 
longed for  several  weeks.  The  heart,  liver  and  kidneys  should  be 
examined,  and  the  urine,  to  eliminate  the  hypothesis  of  purpuras 
characterising  an  organic  disease. 

Hot  drinks  and  milk  with  Vichy  water  may  be  given.  The  throat 
should  be  examined,  and  the  urine  for  albumen  and  sugar,  as  long 
as  the  eruption  remains.  Purpura  always  requires  a  guarded  prog- 
nosis; but  in  this  case  it  is  benign. 

WERLHOFF'S  DISEASE. 

This  is  an  acute  purpura  with  severe  characters,  which  is  seldom 
seen  except  between  the  ages  of  5  and  15  years.  It  begins  with 
uncontrollable  bleeding  of  the  nose,  generally  at  night.  The  body 
is  covered  with  ecchymoses.  The  conjunctivas,  the  mucous  mem- 
brane of  the  mouth,  the  bed  of  the  nails,  and  all  the  visible  surfaces 
are  riddled  with  hsemorrhagic  points.  The  temperature  is  101°  to 
102°  F.,  and  the  pulse  rapid;  there  is  intense  thirst,  breathlessness 
and  distress.  The  haemorrhages  may  cause  one  to  fear  syncope 
and  even  be  fatal.  In  the  majority  of  cases,  however,  this  syndrome 
terminates  by  cure ;  the  haemorrhage  ceases  and  is  not  renewed. 
From  day  to  day  the  ecchymoses  disappear  and  the  general  health 
of  the  child  improves.     Convalescence  is  rapid  and  complete. 

The  cause  of  this  disease,  or  whether  it  is  a  toxaemia,  toxinaemia 
or  septicaemia,  is  unknown.  The  treatment  is  symptomatic.  The 
nasal  fossae  should  be  plugged,  with  care  not  to  cause  an  accidental 
erosion.  The  effect  of  ergotine  is  doubtful.  Solution  of  adrenalin 
(i  in  1000)  may  be  applied  to  the  bleeding  points,  and  serves  to 
gain  time.  (The  following  mixture  should  be  taken  during  24 
hours : — 

Chloride  of  Calcium 4  to  6  grammes  60  to  90  grains 

Rum 30  grammes  ^j 

Distilled  water 40  grammes  Bi /<4 

Syrup  of  bitter  oranges  .    .    .         50  grammes  $iyi 


PURPURAS.  507 

During   convalescence    a    substantial    and    strengthening    diet    is 
indicated,  combined  with  sea  air,  etc. 


ACUTE    FEBRILE    PURPURA. 

In  the  course  of  pleurisy,  pneumonia  or  acute  articular  rheuma- 
tism a  purpuric  eruption  may  arise,  apparently  allied  to  septicaemia, 
and  may  have  all  degrees  of  severity.  Like  all  purpuras,  this  erup- 
tion is  more  marked  on  the  limbs  and  lower  half  of  the  body.  The 
purpuric  spots  may  be  confluent.  The  general  condition  indicates 
the  gravity  of  the  prognosis,  which  may  be  relatively  good, 
mediocre  or  bad.  The  septicaemia  is  the  thing  to  be  feared,  the 
purpura  only  giving  evidence  of  it.  The  older  treatment  was  symp- 
tomatic but  at  the  present  time  the  injection  of  colloidal  silver  into 
the  veins  should  be  tried,  as  it  appears  to  have  no  danger. 

Colloidal  silver 5  to  lo  centigrammes 

Distilled  water 5  to  lo  grammes 


CHRONIC   PURPURA   OF   ORGANIC   DECAY. 

Many  overworked  subjects,  after  the  age  of  45  or  50,  suffer 
from  recurrent  purpura  of  the  legs  and  thighs.  These  attacks  may 
be  accompanied  by  a  certain  degree  of  general  malaise,  sometimes 
simply  heaviness  of  the  lower  limbs.  Subinvolutive  crops  of  fresh 
purpuric  macules,  some  yellowish  purple,  others  yellow  in  course  of 
disappearance,  are  often  seen.  Sometimes  there  is  local  varix  and 
some  oedema. 

The  eruptions  are  of  doubtful  prognosis,  for  they  are  nearly 
always  seen  when  the  general  health  is  already  affected.  Sometimes 
there  is  cardio-renal  disease  with  dyspnoea,  palpitation,  "bruit  de 
galop,"  albuminuria  and  malleolar  oedema.  Such  cases  may  have 
ursemic  attacks  one  or  two  years  later. 

At  other  times  there  is  diabetes  which,  apart  from  the  purpura, 
causes  a  yellow  dermatitis  of  the  legs,  with  a  tendency  to  ascend 
(p.  300).  Or  there  may  be  diabetes  insipidus  with  polyuria,  the 
urine  being  non-toxic  for  animals,  which  indicates  retention  of 
excreta  by  the  liver  or  kidney.  Lastly,  purpura  is  sometimes  seen 
in  cachexia  due  to  cancer,  tuberculosis  or  any  other  cause. 


598  PURPURAS. 

In  these  cases  purpura  is  only  the  demonstration  of  a  state  of 
intoxication  of  internal  origin.  The  treatment  does  not  come 
within  the  domain  of  dermatology  and  varies  much  according  to 
the  difTerent  conditions  of  which  it  is  symptomatic. 


VARIOLA.    VARIOLOID.    VARICELLA. 
VARIOLA. 

Variola  is  an  eruptive,  specific,  contagious  fever;  inoculable  and 
epidemic.  Its  incubative  period  is  from  lo  to  12  days.  Its  invasion 
is  marked  by  grave  general  symptoms ;  intense  fever,  severe  rigors, 
great  pain  in  the  back,  anxiety,  nausea,  vomiting,  agitation  or  pros- 
tration. There  are,  however,  benign  forms  of  which  the  onset  is 
less  severe.  After  2  or  3  days  of  increasing  symptoms,  the  tempera- 
ture remaining  at  104°  F.,  or  higher,  rubeoliform  and  scarlatiniform 
rashes  appear  in  the  natural  folds,  on  the  abdomen  and  chest;  and, 
in  ha^morrhagic  variola,  purpura.  The  shorter  the  period  of 
invasion  the  more  severe  the  variola  and  inversely. 

The  eruption  may  be  discrete,  coherent  or  confluent.  Each  ele- 
ment commences  as  a  papule  which  becomes  a  vesicle,  and  then  a 
pustule.  But  this  succession  of  changes,  except  the  last,  is  seldom 
observed.  What  are  seen  are  umbilicated  vesico-pustules,  circled 
with  red  areola,  varying  in  size  and  number,  and  sometimes  fused 
together. 

The  eruption  predominates  on  the  face,  which  is  red,  swollen  and 
pustular  and  may  become  repulsive.  The  eruption  exists  on  all 
the  mucous  membranes ;  hence,  dysphagia,  dyspnoea  and  suppurative 
conjunctivitis.  The  temperature  falls  the  day  before  the  eruption, 
then  returns  and  increases  with  it.  It  may  reach  iO-i°  or  106°  F. 
Towards  the  12th  day  the  desiccation  of  the  pustules  commences. 
Those  which  are  not  open  become  crusted,  and  the  crusts  are 
detached  and  form  again  with  diminished  size.  This  period  lasts  for 
3  or  4  weeks. 

I  shall  only  mention,  by  the  way,  the  complications  of  variola; 
furuncle,  abscess,  gangrene,  blindness  from  panopthalmitis,  or  cor- 
neal cicatrices,  otitis  and  deafness,  necrosis  of  the  cartilages  of  the 
larynx,  broncho-pneumonia,  purulent  pleurisy,  pulmonary  gangrene, 
endocarditis,  pericarditis,  myocarditis,  phlegmasia,  orchitis  and 
suppurative  parotitis,  etc.     All  these  may  occur. 

The  contagion  is  conveyed  by  the  scabs  and  may  occur  at  any 
period  of  the  disease,  especially  at  the  time  of  desiccation.  In 
countries  where  vaccination  is  unknown  or  badly  practised  (Cochin- 
China)  an  epidemic  may  kill  four-fifths  of  the  population  of  a  con- 


6oo  VARIOLA.     VARIOLOID.     VARICELLA. 

taminated  village.  {Jcanschne).  X'ariola  in  pregnant  women  kills 
the  foetus,  even  at  term,  in  three  or  four-fifths  of  the  cases.  The 
treatment  of  variola  is  symptomatic.  Isolation  of  the  patient  is 
necessary  and  permanent  antisepsis  of  the  skin  and  mucous  mem- 
branes. All  the  persons  in  the  patient's  house  should  be  revaccin- 
ated,  although  it  may  be  too  late  and  evolve  with  the  variola.  (See 
Vaccination  (p.  281.) 

Varioloid  is  only  attenuated  variola  in  the  form  of  a  benign 
eruptive  fever.  In  people  who  have  been  vaccinated  it  is  reduced 
to  a  few  pustules,  and  lasts  for  8  or  10  days.  The  objective  symp- 
toms of  the  elementary  lesion,  however,  remain  typical. 


VARICELLA. 

Varicella  is  a  contagious  and  specific  eruptive  fever,  distinct  from 
any  other.  It  has  been  wrongly  compared  to  variola.  Its  anatomi- 
cal lesions  are  quite  peculiar;  consisting  in  multinuclear  epidermic 
cells  occurring  free  in  the  vesicle  or  under  it.  This  character  con- 
firms its  specific  nature. 

The  incubation  is  14  days,  and  the  period  of  invasion  lasts  a  day 
or  two,  with  a  temperature  of  101°  F.,  and  very  few  functional  or 
general  symptoms.  The  eruption  is  generally  discrete,  and  com- 
posed of  40  or  50  elementary  lesions  irregularly  scattered  over  the 
body.  These  elements  consist  in  soft  bulhe  of  various  sizes,  filled 
with  yellow  fluid,  the  size  of  a  small  cherry  stone,  rounded  but 
irregular,  and  apparently  constricted  by  internal  bands,  and 
often  conglomerated  in  twos  and  threes.  Each  bulla  has  a  thin 
circumferential  zone  of  erythema.  The  eruption  is  pruriginous  and 
the  bulla;  are  converted  by  scratching  into  erosions  resembling 
impetiginous  lesions.  The  eruption  proceeds  by  subinvolutive 
crops,  some  elements  undergoing  resolution  while  new  ones  appear. 
Vesiculation  may  occur  on  the  mucous  membrane  of  the  mouth, 
pharynx,  conjunctiva  and  nostrils ;  but  this  is  not  constant. 

The  phase  of  desiccation  is  rather  slow  and  the  crusts  are  often 
destroyed  by  scratching.  On  the  scalp,  where  they  are  frequent, 
they  look  like  the  remains  of  an  eruption  of  impetigo  of  Bockhart 
(p.  183).  A  cicatrix  may  be  produced  in  the  situation  of  some  ele- 
ments, by   the   depth   of  the   vesicle,   secondary    suppuration    and 


VARIOLA.     VARIOLOID.     VARICELLA.  6oi 

The  benignity  of  varicella  is  practically  constant ;  and  grave 
complications  mentioned  in  the  text  books  are  very  little  to  be 
feared.  There  is  no  treatment  required  except  low  diet  and  rest 
in  bed  during  the  fever,  and  local  antipruriginous  applications. 


SYNDROMES   WITH   BULLOUS   LESIONS. 

In  this  chapter  I  have  united  the  clinical  picture  of  the  different 
diseases  or  syndromes  which  are  accompanied  normally  or  inci- 
dentally with  bullous  lesions.  For  the  most  part  these  affections 
have  nothing  in  common  but  their  objective  resemblance. 

Bullous    urticaria    is    a    rarity    which    has    been} 

f- Bullous      urticaria  p.  535 
studied  elsewhere J 

Acute  benign  epi- 


Certain  authors  have  described  acute  benign  pem- 
phigus, zuhich  is  only  streptococcic  impetigo   .    .    . 


demic    pemphi- 
gus   p.  603 


Medicamentous 
After  these  I  shall  reviezi-  the  most  common  trau- 1      j^yH^^jg     ^       _ 

matte  or  medicamentous  bullous  eruptions  .    .    .    .  j      ^.^^^  ^ 

There  arc  polymorphous  erythemas,  accompanied]  Polymorphous 
or  not  by  erythema  nodosa,  the  lesions  of  which  I     bullous     erythe- 
are  vesicular  or  bullous J      ma p.  604 

In    contrast   with    benign    bullous   polymorphous]  .    r      ■ 

i_      ..I       J  ,      •  s    *-^   ^    h^...      Acute    infectious 

ervthema.    may    be    placed    acute    infectious    pern-  y 

,  ■            .  •  7    •            I       ;           i  t  1  pemphigus    .    .   p.  604 

phigus,  which  ts  nearly  always  fatal J 

\  Erythema      nodo- 
.    .    .  and   severe   infectious    erythema   nodosum^     ^^^  p.  605 

After  this  I  shall  consider  the  painful  /jo/jimor-l  Polymorphou  s 
phous  dermatitis   (Duhring-Brocq) J      dermatitis      .    .   p.  605 

Lastly  I  shall  say  a  few  words  on  the  pemphigus^ 

,   .r  -.IT  II  -J   ;     1  empnigus       veg^ 

vegetans  of  Neumann,  with  buccal  and  ano-genital  \-       ^  . 

*  '         ,  ,,      ,      ,  •     ,•  etans p.  009 

localisation   and  usually   fatal   termination   .    .    .    .  j 

.    .    .  On  the  pemphigus  foliaceus  of  Cas^naz'^,"!  Pemphigus       foli- 
with  Hat  bullce  developing  on  chronic  erythrodermia  J      aceus p.  610 

Lastly   I   shall   mention    benign    traumatic   pemA  -praumatic       pem- 
phigus,    which    is    generally    consanguineous    and  I     phigus  p  610 

hereditary J 

.    .    .  and  the  benign  pemphigus  of  hysteria  .    .  I  Hysterical       pern- 

•^      phigus    ....   p.  610 


GROUP   OF   DERMATOSES   WITH    BULLOUS   LESIONS. 

This  group  is  very  artificial  and  constituted  by  diseases  of  differ- 
ent nature  and  evolution.  This  reunion  must  only  be  regarded  as 
a  symptomatic  grouping,  from  which  the  clinician  must  form  his 
diagnosis  and  treatment. 


SYNDROMES  WITH   BULLOUS   LESIONS.  603 

ACUTE    BENIGN    PEMPHIGUS    OF    THE    NEWLY    BORN. 
ACUTE    EPIDEMIC    PEMPHIGUS    OF    ADULTS. 

These  names  have  been  incorrectly  given  to  true  impetigo  (see 
P-  573)  :  phlyctenular  or  bullous  streptococcic  epidermatitis  in  its 
florid  forms.  Impetigo  has  been  described  in  its  usual  situation  with 
the  lesions  of  the  face.  In  this  article  (p.  7)  will  be  found  indi- 
cations of  the  different  paragraphs  concerning  the  same  affection 
in  its  different  localisations,  and  its  treatment.  The  name  of  pem- 
phigus given  to  these  cases  is  an  important  error  in  nosography,  as 
we  shall  see  later  on  (p.  604). 

BULLOUS  MEDICAMENTOUS  ERUPTIONS. 

Eruptions  of  toxic  origin  are  nearly  all  polymorphous.  Thus 
medicaments,  the  toxic  eruptions  of  which  are  generally  erythema- 
tous, acneiform  or  vegetating,  sometimes  cause  a  characteristic  bul- 
lous eruption.  With  this  reserve  the  two  drugs  which  most  often 
cause  bullous  eruptions  are  antipyrine  and  iodide  of  potassium. 

Antipyrine  gives  rise  to  rashes  resembling  those  of  polymorphous 
erythema.  These  lesions,  instead  of  especially  affecting  the  ankles, 
wrists  and  neck,  as  in  polymorphous  erythema,  may  occur  scat- 
tered over  the  body,  without  regional  localisation,  and  these  rashes 
may  become  phlyctenular  and  bullous,  as  in  erythema  multiforme. 

Iodide  of  potassium  causes  erythema,  vesicles,  phlyctenules,  bullae, 
patches  of  cutaneous  sphacelation,  vegetating  lesions,  etc.,  which 
may  assume  a  remarkable  and  most  severe  aspect.  Nothing  enables 
us  to  foretell  the  cases  in  which  these  drugs,  which  are  usually  well 
tolerated,  will  produce  such  accidents.  The  treatment  consists  in 
cessation  of  the  cause,  rupture  of  the  bullae,  moist  dressings  and 
sub-carbonate  of  iron  ointment  ( i  in  40) . 

BULLOUS  ERUPTIONS  FROM  ALIMENTARY 
INTOXICATION. 

These  are  rare,  but  may  occur  after  ingestion  of  all  tainted  foods : 
game,  pork,  preserves,  mussels  and  shellfish.  Most  commonly  "these 
eruptions  are  erythematous  and  urticarial,  and  we  have  studied  them 


604  SYNDROMES    WITH    BULLOUS    LESIONS. 

previously.     The  treatment  is  the  same  as  for  the  more  common 
types  (p.  534). 

SIMULATED    BULLOUS    LESIONS. 

For  Hysterical  Pemphigus  see  page  6io. 

BENIGN  BULLOUS  ERYTHEMA  MULTIFORME. 

Erythema  multiforme,  the  different  regional  localisations  of  which 
we  have  studied  in  their  proper  places,  consists  usually  of  erythe- 
matous, circular  lesions  in  the  form  of  a  rosette.  But  the  more 
marked  the  lesion  the  greater  the  tendency  of  the  lesions  to  become 
phlyctenular  or  bullous.  In  certain  cases  each  patch  is  replaced  by 
a  soft  bulla.  Even  in  these  cases  the  polymorphous  erythema  pre- 
serves its  essential  characters,  its  localisations  on  the  neck  and 
extremities,  and  among  the  bullous  lesions  a  few  circinate  erythema- 
tous patches  may  be  found  which  confirm  the  diagnosis. 

The  causes  of  bullous  erythema  multiforme  are  no  better  known 
than  those  of  the  usual  form.  The  treatment  is  palliative  and  the 
lesions  have  a  tendency  to  rapid  spontaneous  cure. 

Benign  Erythema  Nodosum.  Erythema  nodosum  is  a  form  of 
erythema  multiforme.  These  red,  benign  nodosities,  sensitive  to 
touch  and  pressure,  disseminated  on  the  lower  limbs,  generally 
accompany  an  evident  erythema  multiforme.  Treatment  by  rest  and 
sedatives  is  sufficient  to  dispel  these  lesions.  The  pathogeny  of  the 
lesions  is  only  hypothetical  (p.  299). 

ACUTE    INFECTIOUS    PEMPHIGUS. 

This  is  a  rare  and  not  well  understood  disease,  occurring  in  per- 
sons who  are  exposed  by  their  occupation  to  handle  tainted  meat  and 
bones:  butchers,  knackers,  tripers  and  cooks.  The  patient  is  nearly 
always  pricked  in  some  point,  but  no  local  signs  are  produced  at  this 
point  except  a  diffuse  painful  redness.  After  one,  two  or  three 
days  an  infectious  state  develops,  which  increases  every  hour  and  is 
accompanied  by  rigors,  hyperpyrexia,  delirium,  insomnia  and  pains 
in  the  back  and  head.  An  eruption  of  yellow  bullae  then  appears, 
which  are  more  or  less  discrete  or  abundant,  of  different  sizes,  and 


SYNDROMES    WITH    BULLOUS    LESIONS.  605 

circled  with  red ;  these  may  rupture  or  pass  on  to  suppuration :  other 
bullae  arise  in  repeated  sub-involutive  crops.  The  temperature  may 
reach  106°  F. ;  coma  supervenes,  and  death  generally  occurs  in  5 
to  15  days.  A  cure  is  exceptional,  but  may  be  produced  by  gradual 
amendment  of  the  objective  and  general  phenomena. 

The  bacteriology  of  this  affection  remains  to  be  studied.  The 
treatment  is  entirely  symptomatic,  but  intra-venous  injections  of 
coUargol  should  be  tried  without  delay. 

Severe  infections  erythema  nodosum.  In  1892  I  observed  with 
Orillard  a  case  which,  up  to  the  present  time,  remains  unique.  A 
cook  was  supposed  to  be  stung  on  the  thumb  by  a  fly.  Lymphangitic 
oedema  followed  with  progressive  general  phenomena.  Then  on 
different  parts  of  the  body,  but  chiefly  on  the  affected  arm,  appeared 
a  number  of  red,  painful  nodosities,  about  the  size  of  a  nut.  There 
were  no  bullous  lesions. 

The  general  symptoms  became  grave;  hyperpyrexia,  prostration, 
coma  and  death  2  days  after  admission  to  hospital.  The  autopsy 
shewed  that  each  swelling  was  centred  by  an  enormously  dilated 
and  throm.bosed  vein.  The  thrombojis  was  constituted  by  a  compact 
colony  of  streptocccci. 

PAINFUL    POLYMORPHOUS    DERMATITIS. 
DERMATITIS  HERPETIFORMIS   OF  DUHRING. 

Under  these  two  names  is  designated  a  dermatosis  of  unknown 
cause,  generally  chronic,  lasting  for  months  or  years,  paroxysmal  and 
characterised  by  erythematous,  papular,  urticarial,  vesicular,  bullous 
or  pustular  eruptions.  The  lesions  may  be  agminated  in  groups  and 
circles  or  may  be  disseminated.  It  occurs  in  acute  or  sub-acute 
forms,  in  chronic  forms  with  successive  crops  and  in  connection  with 
pregnancy  (herpes  gestationis) . 

(i)  The  acute  forms  seem  to  be  the  first  attack  of  a  painful  poly- 
morphous dermatitis  which  becomes  arrested  and  disappears.  They 
consist,  like  the  chronic  form,  in  a  polymorphous  eruption,  accom- 
panied by  functional  phenomena  of  marked  pruritus  and  smarting, 
without  general  S}'niptoms.  But  in  this  form  the  lesions  develop 
abruptly  and  end  in  cure. 

These  eruptions,  preceded  or  accompanied  by  painful  symptoms, 
commence  on  the  wrists  and  dorsal  surface  of  the  hands  and  on  the 
limbs,  generally  in  the  form  of  urticarial  patches  which  soon  become 


6o6 


SYNDROMES    WITH    BULLOUS    LESIONS. 


transformed,  the  eruption  being  always  polymorphous;  at  the  same 
time  urticarial  and  vesiculo-bullous,  etc.  The  disease,  even  when 
limited  to  a  single  attack,  always  occurs  in  successive  crops,  of 
which  the  first  are  usually  the  most  severe,  and  of  which  the  ele- 
ments may  differ  in  the  different  crops  as  much  or  more  than  they 
differ  between  themselves  in  the  same  crop. 

(2)  The  chronic  forms,  in  successive  crops,  also  begin  with  pain- 
ful phenomena  accompanying  or  preceding  the  lesions.  The  latter 
are  erythematous  at  first,  vesiculo-bullous  or  even  pustular  and 
generally  commence  on  the  limbs,  especially  the  fore-arms.    The 


Figr.  216.     Bullous  form  of  painful   polymorphous  dermatitis.      Chronic 
pemphigus  of  most  authors.     Brocq's  patient.     Photo  by  Sottas. 

successive  crops  increase  in  number  and  may  cover  the  whole 
body ;  the  limbs  generally  present  the  most  numerous  lesions  ;  the 
palms  of  the  hands,  soles  of  the  feet  and  the  face  are  relatively 
free.  Circumscribed  varieties  of  the  disease  occur  which  are  lim- 
ited to  one  or  more  regions ;  but  this  is  exceptional.  In  both  forms 
of  the  disease  the  polymorphism  and  the  preservation  of  the  gen- 
eral health  are  almost  constant  characteristics. 

Lesions  of  the  mucous  membranes  suggest  that  the  old  bul- 
lous hydroa,  when  it  is  recurrent  and  accompanied  by  lesions  of 
the  body,  is  only  a  form  of  painful  polymorphous  dermatitis.    In 


SYNDROMES    WITH    BULLOUS    LESIONS. 


607 


spite    of   the    habitual    polymorphism   of   the    disease    cases    occur 

of  which  tlio  objective  type  is  almost  systematised.  For  in- 
stance, the  pure  herpetiform  va- 
riety (Brocq),  the  elementary 
topography  of  which  is  that  of 
the  elements  of  true  herpes ;  and 
the  circinate,  pseudo-trichophy- 
tic  variety,  etc.  The  most  re- 
markable character  of  the  evo- 
lution of  the  disease  is  its  par- 
oxysmal course.  It  proceeds 
always  by  more  or  less  severe 
and  separate  attacks,  and  each 
attack  consists  of  distinct  sub- 
involutive  crops. 

This  disease  may  occur  in 
childhood  (hydro  pucrorum  of 
Unna). 

It  presents  a  maximum 
between  16  and  20  years, 
and  a  more  marked  maxi- 
mum period  from  47  to  62 
years  {Brocq).  It  occurs  in 
both  sexes. 

The  role  of  pregnancy  as  an 
accessory  cause  led  to  the  sep- 
arate description  of  herpes 
gestationis  {Milton)  as  a  special 
affection  of  pregnancy,  before 
the  history  of  polymorphous 
dermatitis  in  general  was 
known.  In  the  gravoid  forms 
the  eruption  may  begin  at  any 
period  of  pregnancy.  It  may  in- 
crease    or     diminish     with    the 

couise  of  pregnancv,  persist  till  parturition,  or  continue  afterwards. 
All  kinds  of  internal  treatment  have  been  prescribed  for  painful 

polymorphous    dermatitis,   but   none   give   any   appreciable   results. 

Sedatives  may  be  useful  in  alleviating  the    subjective    phenomena 

when  these  are  very  pronounced. 


Fig.  217.  Circumscribed  form  of  pain- 
ful polymorphous  dermatitis. 
Brocq's    patient.      Photo    by    Sottas, 


608  SYNDROMES   WITH    BULLOUS    LESIONS. 

External  treatment  is  no  more  satisfactory  than  internal.  Anti- 
pruriginous  lotions,  baths,  moist  dressings  and  ointments  have  all 
been  recommended.     The  mildest  applications,  such  as  fresh  lard, 


Fig.  818.     Herpetiform    variety    of   painful    polymorphous    dermatitis. 
(Brocq's   patient.      Photo   by    Sottas.) 

linimentum  calcis  and  cold  cream  are  those  which  give  most  relief 
to  the  patient. 

In  severe  cases  the  patient  should  be  well  dusted  with  powdered 
starch,  or  talc  and  oxide  of  zinc,  without  dressings.  Fatal  cases  of 
polymorphous  dermatitis  have  been  reported,  but  nearly  all  cases  are 
cured.  However,  their  duration,  which  is  reckoned  by  years,  and 
their  painful  symptoms,  render  them  a  formidable  disease. 


SYNDROMES    WITH    BULLOUS    LESIONS. 
PEMPHIGUS   VEGETANS    OF    NEUMANN. 


609 


Fig.  319.     Pemphigus    foliaceus    fAudry's    patient). 


39 


This  is  a  rare  dis- 
ease, of  unknown  ori- 
gin, occurring  at  all 
ages  and  in  both  sexes. 
It  commences  by  phlyc- 
tenules in  the  mouth 
and  on  the  palate ;  bul- 
lae also  occur  in  the 
anal  and  inguino-geni- 
tal  regions,  the  axillae, 
the  folds  of  flexion, 
the  interdigital  spaces 
(especially  on  the  foot) 
and  around  the  nails. 
Each  bullae  leaves  a 
deep  ulceration  which 
soon  becomes  filled 
with  exuberant  granu- 
lations ;  the  ulcers  en- 
large and  coalesce,  and 
others  form  around  the 
first.  They  exhale  a 
foetid  gangrenous 
odour  and  produce  an 
ichor  ous  discharge. 
Without  ex  c  e  p  t  i  o  n 
none  of  the  bullae  un- 
dergo resolution  nor 
heal.  The  disease  pro- 
ceeds by  successive 
outbreaks  and  the  gen- 
eral health  soon  suflfers, 
but  there  is  no  fever. 
Dysphagia  incre  a  s  e  s 
the  malnutrition,  the 
patient  soon  becomes 
cachectic,  and  death  oc- 
curs in  3  to  7  months. 


6i  SYNDROMES    WITH    BULLOUS    LESIONS. 

This   termination  is   the  rule  and  no  known  treatment   is  of  any 
value. 

PEMPHIGUS    FOLIACEUS. 

This  disease  is  rare  and  more  common  in  women  of  middle  or 
advanced  age.  Its  cause  is  unknown.  It  begins  by  an  eruption  of 
bullae,  situated  on  the  trunk  more  than  on  the  limbs.  A  progressive 
exfoliating  erythrodermia  is  quickly  established,  on  which  fresh 
crops  of  bullae  appear.  The  bullae  are  seldom  tense  and  round,  but 
more  often  flabby  and  wrinkled.  When  the  disease  is  mature, 
bullae  and  squames  are  present  all  over  the  body  and  limbs ;  and  on 
parts  of  the  skin  apparently  healthy,  the  horny  epidermis  can  be 
raised  by  the  finger,  being  separated  from  the  rest  of  the  epidermis 
by  diffuse  infiltration. 

General  phenomena  are  slight,  but  a  mild  intermittent  fever  ( ioo°- 
loi°)  lasting  several  months  has  been  noted.  The  subjective  phe- 
nomena consist  in  variable  degrees  of  pruritus  and  pain.  The  evo- 
lution of  the  disease  is  slow,  lasting  for  years  and  terminating  almost 
invariably  in  death,  from  diarrhoea,  broncho-pneumonia,  or  some 
intercurrent  affection. 

There  is  no  known  efficacious  treatment,  but  the  symptoms  may 
be  a  little  relieved  by  the  local  treatment  recommended  for  painful 
polymorphous  dermatitis  (p.  607). 

PEMPHIGUS    CONSECUTIVE    TO    TRAUMATISM. 

I  shall  only  mention  by  the  way  this  strange  affection,  which  is 
usually  consanguineous  and  hereditary.  The  affected  subjects  pre- 
sent bullae  at  all  points  where  continuous  pressure  or  friction  is  exer- 
cised ;  even  when  moderate,  after  walking,  etc.  The  phenomenon  is 
produced  by  various  causes  during  life,  and  is  not  accompanied  by 
any  general  disorder. 

HYSTERICAL    PEMPHIGUS. 

The  name  indicates  the  conditions  under  which  this  occurs.  It 
resembles  exactly  the  blisters  produced  by  blistering  fluids,  and  may 
even  in  some  cases  be  produced  by  this  cause.  It  occurs  in  recur- 
rent attacks,  generally  in  very  neurotic  subjects.  It  is  compatible 
with  perfect  health  in  hysterical  persons. 


DYSCHROMIAS    (MELANODERMIA-VITILIGO). 

SCLERODERMIA. 

This  chapter  describes  the  rare  morbid  conditions  which  we  have 
not  had  occasion  to  study  in  the  course  of  this  vohune,  or  rather  it 
traces  in  a  few  hues  the  evohition  of  diseases  with  multiple  locahsa- 
tions,  of  which  each  locaHsation  has  been  studied  in  its  proper  place. 
It  is  thus  a  synopsis  of  the  different  dyscromias  and  sclerodermias,. 
and  in  reading  it  the  special  subject  on  which  further  information 
is  required  may  be  referred  to  in  the  book.^ 


Developmental 
dyschromias     .   p.  6l2 

Nervous      dys- 
chromias   ...   p.  612 


Haematic  dyschro- 


•u;«,1  T  o  X  i 
.    .  J       mias 


Local 
mias 


dyschro- 


dyschro- 


Albinisiit,  pigincnfaiy  navi.  lentigo,  cphclidcs, 
xeroderma  pigmentosum,  neurofibromatosis  of 
Recklinghausen 

Addison's  disease,  tuberculous  melanodcrmia, 
acanthosis  nigricans,  chloasma,  pigmentary  syph- 
ilide,  leprous  dyschromias,  dyschromias  of  nervous 
diseases,  vitiligo 

Dyschromias  of  lymphadenitis,  of  Icuccemia,  of 
mycosis  ftingoides,  malarial  cachexia,  bronze 
diabetes 

Arsenical    mclanodermia,    antipyrine,    argyrism 
saturnism 

Dyschromias  caused  by  heat  and  revtdsives,  and 
parasitic  traumatism  (plitiriasic  melanodermia)  ; 
local  mclanodermia  consecutive  to  eruptions  .    .    . 

We  shall  next  study  the  sclerodermias  of  w/riV/il  Sclerodermias     in 
four  types  may   be  described J      general  .   . 

There  is  a  general,  chronic,  cutaneous  progressive} 
disease,  which  the  name  of  sclerodermia  describes  ISclerodermia 
perfectly J 

A  morbid  form,  identical  in  course,  duration  and  1 
termination,   commences   on    the   hands:    hence    ///f  ^  Sclerodactylia 
name    of   sclerodactylia J 

There  is  also  a  form  of  sclerodermia  in  patches^ 
called  ivhite  morphaa  of  much  less  grave  prognosis,  [■  Morphoea  .    . 
with  divers  localisations J 

Lastly,  an  atrophic  sclerosing  process  in  long 
patches,  zvhich  is  very  distinct  from  the  preceding, 
in  spite  of  its  common  name  of  morphcca  in  bands 


p.  613 

p.  614 

p.  614 

p.  615 
p.  615 

p.  61S 
p.  616 


M  o  r  p  h  ce  a        i  n 
bands p.  617 


1  This  chapter  was  inspired  by  the  remarkable  summary  which  J.  Darier 
has  given  this  subject  in  the  Pratique  dermatologique. 


6i2  DYSCHROMIAS    (MELANODERMIA-VITILIGO). 

DEVELOPMENTAL    DYSCHROMIAS. 

Albinism  consists  in  the  absence  of  pigment  from  the  nial- 
pighian  layer;  a  form  of  degeneration  which  is  usually  accompanied 
by  several  others,  such  as  semi-cretinism,  deafness,  etc. 

Pigmentary  Naevi  and  Lentigo  are  due  to  patches  of  localised 
hyperchromia.  They  are  congenital  lesions  even  when  they  grow 
after  birth  (p.  6).  Pure  pigmentary  naevi  are  rare,  they  are  gen- 
erally more  or  less  hairy  or  warty  (p,  5).  Lentigo  may  be  the 
point  of  origin  of  melanotic  n^evo-carcinoma. 

Ephilides  or  brown  spots  (p,  5),  which  are  not  congenital,  are 
more  marked  in  summer.  In  spite  of  these  differences,  they  have  a 
•close  relationship  to  nsevi. 

Xeroderma  pigmentosum  of  Kaposi  (p.  6)  is  composed  of 
lenticular  patches  like  ephelides,  but  unequal  in  colour  and  size.  Be- 
tween them  there  are  atrophic  cutaneous  patches  and  telangiectases. 
I  have  already  described  the  evolution  of  this  rare  hereditary  affec- 
tion, which  is  localised  on  the  face  and  extremities  (p.  341). 

Neurofibromatosis  of  Recklinghausen.  This  rare  affection 
presents,  apart  from  the  fibrous  tumours  by  which  it  is  accompanied, 
<i  symptomatic  triad :  ( i )  irregularly  disseminated  lenticular  spots  ; 
(2)  nummular  or  elongated  spots  with  clear  margins  of  cafe-au- 
lait  colour  and  zonular  distribution;  (3)  diffuse  melanodermia. 
This  disease  is  consanguineous  and  hereditary  and  often  accom- 
panied by  deficient  intellect. 


NERVOUS    DYSCHROMIAS. 

Addison's  disease  is  characterised  by  progressive  asthenia,  lum- 
bar pains,  digestive  troubles  and  a  dyschromic  localisation  on  ex- 
posed regions. 

Tuberculous  Melanodermia  appears  to  be  an  accidental  copy 
of  Addisonian  melanodermia  when  tuberculosis  has  aifected,  with 
the  peritoneum,  the  abdominal  sympathetic,  the  suprarenal  plexus 
or  the  suprarenal  capsule. 

Acanthosis  nigricans  has  been  studied  on  pages  42  and  247, 
with  its  pigmentation  of  the  mouth  and  cutaneous  folds,  and  cuta- 
neous papillary  hypertrophy.  It  is  connected  with  malignant  abdomi- 


DYSCHROMIAS    (MELANODERAIIA-VITILIGO).  6ri 

nal  tumours  and  may  have  the  same  sympathetic  origin  as  the  two 
preceding  diseases. 

Chloasma,  or  uterine  mask  (p.  26),  may  be  also  hypothetically 
connected  with  an  abdominal  sympathetic  origin. 

Pigmentary  Syphilide  of  the  neck  (p.  246)  seems  to  be  a  pro- 
topathic  pigmentary  disorder,  occurring  without  any  previous  macu- 
lar or  papular  lesion.  There  is  a  syphilitic  leuodermia,  which  is  not 
exclusively  localised  to  the  neck  and  is  constituted  by  white,  slightly 
atrophic  spots,  consecutive  to  a  pre-existing  macular  or  papular 
eruption. 

Leprous  Dyschromias.  In  leprosy  (p.  655)  there  occur: — (i) 
The  erythematous  spots  of  leprous  roseola,  which  remain  pigmented 
and  visible  long  after  the  erythema  has  disappeared.  (2)  primary 
pigmentations,  in  placards  or  spots,  which  are  common  in  the  first 
stage  of  amesthetic  leprosy.  (3)  Dyschromic  spots  of  all  forms, 
which  appear  insidiously  or  by  crops  and  invariably  present  super- 
ficial sensory  disorders.  (4)  Old  lepers  have  often  a  grey  colour 
of  the  infiltrated  skin;  bronze  oedema;  (5)  and  white  or  black  scle- 
rous cicatrices  of  former  tubercles  or  ulcers. 

Daricr  also  mentions  dyschromias  in  many  nervous  diseases : 
hemiplegia,  exopthalmic  goitre,  infantile  paralysis,  facial  hemia- 
trophy, sclerodermia,  etc. 

Along  with  the  nervous  dyschromias  should  be  placed  the  vitiligos. 

Vitiligo  (p.  2y)  is  constituted  by  two  elements,  white  achro- 
mic  spots  and  a  hyperchromic  border.  Its  cause  is  unknown,  although 
it  has  been  observed  after  severe  shocks  and  after  infectious  dis- 
eases. We  have  studied  it  on  the  face  (p.  27) ;  on  the  hands  (p. 
340;  and  on  the  inguino-scrotal  region  (p.  461),  which  are  tiie 
seats  of  election.  The  symptoms  are  chiefly  negative.  It  has  no 
special  functional  symptom  and  is  not  accompanied  by  any  percep- 
tible general  disorder.  Its  spontaneous  cure,  wdien  this  occurs,  the 
extension  of  its  patches  and  their  displacement,  are  no  more  under- 
stood than  their  appearance.  The  connection  of  vitiligo  with  former 
syphilis  or  with  hereditary  syphilis,  with  alopecia  areata  {Cazenavc) , 
or  wath  sclerodermia  are  not  yet  established. 

Bronze  colouration  of  the  skin  occurs  in  Icuccrniia,  lymphadenitis 
and  mycosis  fuugoides. 

In  malarial  cachexia  the  skin  is  of  an  earthy  colour,  grey  or  yel- 
low-ish  brown.  This  is  due  to  a  melanodermia  which  deposits  pig- 
ment under  the  epidermis  in  the  corium. 


45i4 


DYSCHROMIAS    (MELANODERMIA-VITILIGO). 


In  bronze  diabetes  there  is  a  pigment  of  haematic  origin  which  is 
deposited  in  the  dermis. 


i 


I'ig.  230.  Vitiligo 
in  a  sypliilitic. 
(D  a  r  i  e  r's  pa- 
tient.) 


TOXIC    DYSCHROMIAS. 

Arsenical  melanodermia.  This  may  follow 
the  absorption  of  small  doses  given  only  once, 
but  is  more  commonly  associated  with  chronic 
arsenical  poisoning.  This  melanodermia  avoids 
the  extremities  and  is  pronounced  in  the  folds  of 
flexion,  at  points  of  friction,  and  around  and 
underneath  the  cutaneous  lesions  for  which  ar- 
senic has  been  prescribed.  The  colour  is  grey 
and  the  epidermic  surface  is  furfuraceous.  The 
palmar  and  plantar  regions  are  hyperkeratotic. 

Antipyrine  often  causes  an  erythemato-pig- 
mentary  eruption,  especially  marked  on  the  limbs ; 
the  pigmentation  survives  the  erythema,  and  the 
eruption  recurs  at  the  same  points  with  fresh 
doses  of  the  drug. 

Argyria  consists  in  a  deposit  of  silver  under 
the  epidermis  and  in  the  corium  of  the  mucous 
membranes  in  patients  submitted  to  prolonged 
treatment  by  nitrate  of  silver.  It  is  allied  to  the 
blue  line  on  the  gums  and  nails  produced  by  sul- 
phide of  lead  in  saturnism. 


DYSCHROMIAS    OF    LOCAL    ORIGIN. 

In  the  first  place  may  be  mentioned  sunburn,  a  hyperchromia  of 
solar  origin,  caused  by  the  actinic  rays  of  the  spectrum.  Hyperpig- 
mentation  may  be  produced  by  heat  in  parts  of  the  body  which  are 
habitually  exposed  to  it,  as  in  bakers,  blacksmiths,  etc.  The  revul- 
sives and  many  chemical  agents  act  in  the  same  way ;  and  in  a  gen- 
eral way  all  traumatism.  Mechanical  traumatism  by  corsets,  ban- 
dages, shoulder  straps,  and  repeated  scratching  in  the  same  places 
may  have  the  same  efifect.  Phtiriasic  melanodermia  is  an  example 
of  parasitic  traumatism,  the  mechanism  of  which  is  unknown,  since 
it  may  occur  in  the  mouth. 

A  great  number  of  dermatoses  are  followed  by  pigmentation,  ery- 
thema, hsemorrhagic  urticaria,  purpura,  varicose  eczema,  ulcers  of 


DYSCHROMIAS    (MELANODERMIA-VITILIGO).  615 

the  leg,  bullous  eruptions  of  polymorphous  dermatitis,  zona,  im- 
petigo, folliculitis,  papulo-necrotic  tuberculides,  neuro-dermatitis, 
and  lichen  planus.  The  last  has  even  a  characteristic  terminal  phase 
of  pigmentation. 

SCLERODERMIAS. 

Under  this  common  name  are  united  four  syndromes  which 
are  perhaps  different,  and  should,  in  any  case,  be  carefully  dis- 
tinguished from  each  other:  generalised  sclerodennia,  sclerodac- 
iylia,  morphoca  in  patches,  and  inorpha'a  in  bands.  We  shall  say 
a   few   words   on   each   of  these   four   morbid   types. 

They  are  all,  except  perhaps  the  last,  more  common  in  women 
than  in  men,  and  in  young  subjects.  Their  etiology  is  unknown, 
and  their  pathogeny  h}opthetical. 

SCLERODERMIA. 

After  a  hyperaesthetic  phase,  with  pruritus,  pain,  smarting  and 
sometimes  a  transient  sub-acute  phase  resembling  certain  infec- 
tious states,  cutaneous  rigidity  occurs,  affecting  the  nape  of  the 
neck  and  chest,  and  causing  functional  symptoms  such  as  dyspnoea, 
etc.  After  a  variable  period  a  kind  of  hard  oedema  of  the  whole 
skin  is  constituted,  which  appears  infiltrated  and  does  not  pit  on 
pressure.  The  transition  from  healthy  to  diseased  skin  is  insensi- 
ble, and  the  whole  body  is  soon  affected.  On  the  face  and  hands 
the  skin  is  first  increased  in  size  (phase  of  infiltration),  then,  after 
some  weeks  or  months,  it  becomes  contracted  (atrophic  phase). 
It  has  the  characteristic  colour  of  old  wax.  Gradually  all  the  func- 
tions are  abolished,  movements  are  diminished  and  finally  suppressed 
and  the  immobility  of  the  limbs,  in  semi-flexion,  leads  to  muscular 
atrophy.  The  body  assumes  the  aspect  of  a  mummy ;  the  face  is 
immobile,  and  without  wrinkles ;  the  eyelids  half  closed ;  and  the 
thin  lipped  mouth  is  half  open.  This  condition  lasts  from  i  to 
4  years,  sometimes  for  6  to  10  years,  leading  to  progressive  cachexia, 
and  the  scene  generally  closes  with  some  secondary  infection; 
streptococcic  infection,  pneumonia  or  tuberculosis. 

SCLERODACTYLIA. 

The  evolution  of  sclerodactylia  is  very  similar  to  that  of  sclero- 
dermia.   but   the   onset  is   quite   different.       It   commences   in   the 


6i6  DYSCHROMIAS.  (MELANODERMIA-VITILIGO). 

fingers,  the  skin  of  which  becomes  thickened  and  indurated,  and 
assumes  the  colour  and  semi-transparency  of  old  wax.  The  move- 
ments of  the  fingers  are  gradually  abolished. 

The  process  of  sclerodactylia  is  a  double  one.  It  commences 
with  sclerosis  and  thickening,  and  continues  with  atrophy  of  the 
skin  and  subjacent  parts;  and  as  this  process  slowly  extends  to- 
wards the  wrist,  the  skin  of  the  hands  is  still  infiltrated  when  the 
ends  of  the  fingers  are  fusiform  and  pointed  (p.  380).  The  ends 
of  the  fingers  are  white,  waxy  and  cold,  the  circulation  seems  to  be 
interrupted  and  the  atrophy  of  the  ends  of  the  fingers,  like  that  of 
the  skin,  is  progressive.  Indolent  ulcers  are  produced  which  slowly 
destroy  one  or  two  phalanges,  and  a  fragment  of  necrosed  bone  is 
often  extruded   from  the  stump. 

Sclerodactylia  is  by  no  means  limited  to  the  fingers,  but  may 
secondarily  attack  the  wrists,  forearms,  feet,  ankles,  and  the  face. 
This  reproduces  the  process  already  described  in  generalised  sclero- 
dermia.  The  head  seems  to  be  diminished  in  size ;  the  skin  shews 
neither  folds  nor  wrinkles,  and  has  the  appearance  of  being  sculp- 
tured out  of  some  hard  substance;  the  eyelids  do  not  close.  In 
one  case  I  have  seen  the  thickened  sclerotic  resemble  the  normal 
skin,  and  the  patient  could  not  distinguish  day  from  night.  The 
mouth  resembles  a  slit  in  the  fiesh,  and  the  tongue  may  be  affected 
and  become  immobile.  After  6  to  15  years  death  occurs  by  acci- 
dent or  in  the  course  of  progressive  cachexia. 

The  two  morbid  types,  sclerodermia  and  sclerodactylia,  seem 
to  be  analogous  morbid  processes,  and  may  perhaps  be  the  same 
with  different  modes  of  onset.  This  is  not  the  case  with  mor- 
phoea. 

MORPHOEA. 

This  occurs  in  the  form  of  thickened  patches  of  skin,  of  insidious 
growth,  which  feel  like  pieces  of  cardboard.  It  may  affect  any  part 
of  the  body,  but  more  commonly  the  face,  neck,  chest,  groins  and 
thighs.  The  skin  cannot  be  folded  and  seems  to  be  united  to  the 
subjacent  tissues.  The  patches  are  of  various  sizes,  irregular, 
and  with  a  sinuous  border.  The  surface  is  generally  milky  white 
and  each  patch  is  surrounded  with  a  lilac  ring  as  wide  as  the 
finger.  The  patches,  often  only  2  or  3  in  number,  are  sometimes 
numerous    (15-25),   and  may  be  grouped   or   isolated.     Their  ar- 


DYSCHROMIAS    (xMELANODERMIA-VITILIGO).  617 

rangement  is  irregular,  and  never  zonular.  They  may  increase 
and  even  become  displaced;  occasionally  they  retrogress,  leaving 
a  white  atrophic  cicatricial  spot;  but  they  generally  remain  in 
situ. 

Morphoea  is  not  accompanied  by  any  general  condition  and  is 
never  fatal:  thus  differing  essentially  from  sclerodermia.  With- 
out suggesting  any  etiological  connection  between  the  two  diseases, 
one  may  say  that  morphoea  in  patches  copies  the  evolution  of 
fixed  lupus  erythematosus.  The  cause  of  morphoea  is  unknown, 
but  it  has  been  seen  to  occur  after  severe  nervous  shock,  and  some- 
times in  connection  with  vitiligo  or  general  alopecia. 

The  treatment  is  purely  external,  by  bipolar  electrolysis,  prac- 
tised in  the  same  manner  as  for  large  naevi  (p.  5).  This  does 
not  always  succeed,  but  does  no  harm.  High  frequency  has  given 
appreciable  results  in  some  cases. 

Generalised  sclerodermia  and  sclerodactylia  have  no  satisfactory 
treatment. 

MORPHOEA    IN    BANDS. 

I  shall  say  a  few  words  concerning  morphoea  in  bands,  a  rare 
disease,  which,  in  my  opinion,  has  been  incorrectly  connected  with 
morphoea  in  patches.  It  consists  of  cutaneous  bands  which  are 
atrophic  from  the  first,  and  which  gradually  form  on  the  body 
or  the  scalp.     They  are  deep   from  their  commencement. 

On  the  scalp,  where  they  are  permanently  bald,  or  on  the  fore- 
head, a  third  of  the  thickness  of  the  finger  can  be  placed  in  their 
channels.  The  lesions  progress  slowly,  then  become  arrested  in 
growth  and  remain  without  retrogressing.  The  cause  is  unknown 
and  the  treatment  nil.  They  appear  to  me  to  differ  entirely  in 
their  symptoms,  if  not  in  their  evolution,  from  the  patches  of  true 
morphoea. 


TUMOURS    OF    THE    SKIN. 

The  number  of  tumours  of  the  skin  being  considerable  a  certain 
order  is  required  in  their  description ;  but  this  order  is  artificial 
and  can  hardly  be  otherwise. 

I  shall  first  consider  the  retention  cysts  and  similar  benign  tu- 
mours; miliimi  (p.  619),  sebaceous  cysts  (p.  620),  zvens  (p.  620), 
cysts  by  traumatic  epidermic  iuclusiou  (p.  620)  ;  sudoriparous 
cysts;  hydrocystomas  (p.  620),  syuovial  cysts  (p.  621),  hygromas 
(p.  621). 

In  the  next  group  I  shall  study  the  small  benign,  common,  con- 
tagious neoplasms ;  the  small  umbilicated  tumours  of  molluscum 
contagiosum  (p.  621),  and  the  four  types  of  warts;  simple  wart, 
iiat  juveuile  zvart,  seuile  zvart,  papilloma  (p.  622). 

A  third  group  includes  the  syndromes  of  rare  parasitic  tumours, 
due  to  dififerent  causes;  the  multiple  cysts  of  cysticerus  {'^.  623), 
the  multiple  cysts  of  hyphomycosis  of  Ramond  (p.  623),  subcu- 
taneous calcareous  granuloma  of  Milian  (p.  624),  blastomycosis 
(p.  624),  botriomycosis  (p.  624),  and  especially  cheloid  (p.  625). 

The  next  class  comprises  circumscribed  congenital  deformities 
or  naevi  (p.  625).  This  class  is  considerable,  not  only  in  the  num- 
ber of  objective  and  anatomical  types  which  it  includes,  but  espe- 
cially in  the  number  of  morbid  conditions  which  are  more  or 
less  directly  connected  with  it. 

Besides  the  pigmentary  ncevi,  studied  with  the  melanodermias 
(p.  611),  and  the  vascular  ncrvi  mentioned  in  connection  with  the 
face,  the  vascular  tuberous  nccvi  (p.  626)  are  true  angiomatous 
tumours  and  should  find  a  place  here. 

The  same  with  lymphatic  angiomatous  tumours  arising  on  ncevi; 
lymphangiomas  (p.  626). 

The  soft,  flat  or  pedunculated  cutaneous  fibromas,  or  molluscum, 
are  peculiar  nsevi,  and  belong  to  this  group  (p.  627)  ;  also  the 
neuroHbromatosis  of  Recklinghausen  (p.  627). 

The  soft  and  hard  zvarty  nccvi  will  be  considered  next  (p.  628)  ; 
then  symmetrical  adenoma  of  the  face  (p.  628),  and  pseudo-eruptive 
hydradenoma  (p.  630). 

Most  authors  regard  urticaria  pigmentosa  as  a  congenital  disease 
with  nsevoid  tumours   (p.  630). 


TUMOURS    OF    THE    SKIN.  619 

Dermatomyomata  (p.  630)  and  dermoid  cysts  (p.  631)  are  of 
the  same  origin.  I  have  added  calcareous  tuDioiirs  (p.  631),  which 
may  be  caused  by  the  calcification  of  many  kinds  of  pre-existing 
tumours. 

Departing  more  and  more  from  nsevi  of  the  ordinary  type,  we 
shall  consider  the  hard  Hhromas,  consisting  of  more  or  less  multiple 
tumours  (p.  631),  and  the  different  forms  of  lipoma  (p.  631). 
With  these  I  shall  consider  Xaiiilwina  (p.  632),  a  name  which 
covers  several  morbid  entities,  some  of  which  at  least  appear  con- 
nected with  naevi ;  for  in  certain  nsevi  xanthelasmic  cells  are  found. 

We  then  come  to  the  different  malignant  tumours :  sarcomas 
(p.  633),  multiple  pigmentary  sarcomatosis  of  Kaposi  (p.  634), 
generalised  sarcomatosis  of  Perrin  (p.  634),  and  sarcomatous  de- 
generation of  ncevi  (p.  635). 

Cutaneous  sarcomatosis  may  be  secondary  to  a  deep  sarcoma 
(p.  635).  Besides  these  cases  of  multiple  cutaneous  tumours,  a 
single  primary  cutaneous  sarcoma  may  occur  (p.  635).  Lastly, 
there  exists  a  lymphadenoid  sarcomatosis ;  cutaneous  lymphadenoma 
(p.  635),  primary  or  secondary,  with  special  characters. 

Along  with  the  sarcomas  we  shall  place  mycosis  fungoides  (p. 
6^7),  and  cutaneous  lymphadenia  (p.  639). 

We  shall  conclude  this  epitome  with  the  study  of  epitheliomas 
(p.  639)  ;  the  papillary  form,  common  cancroid,  pearly  epithelioma. 
Hat  superficial  epithelioma,  rodent  ulcer,  cpithelio-adenoides,  sec- 
ondary cutaneous  carcinosis,  etc.;  concluding  with  the  special  and 
benign  form  of  epithelioma  of  the  scalp  and  face,  called  cylindroma 
(p.  642 ).i 

MILIUM. 

I  have  already  mentioned  the  small  grains  of  milium  occurring 
on  the  face  (p.  130).  They  are  small  white  cysts  resembling 
grains  of  barley,  enclosed  in  the  thin  skin  of  the  eyelids,  temples, 
cheeks  and  neck.  "Small  epidermic  cysts  developed  sometimes 
at  the  expense  of  the  hairy  follicles  and  possibly  of  the  sebaceous 
glands ;   sometimes  more  or  less  aberrant  and  badly  formed  mal- 

1  In  this  concise  review  of  an  enormous  number  of  clinical  facts,  we 
have  derived  much  assistance  from  many  previous  works,  especially  those 
of  Darier  on  tumours,  Bodin  on  the  xanthomas,  Perrin  on  sarcomas,  Rist 
on  ncevi  and  angioraas,  etc. 


620  TUMOURS    OF   THE    SKIN. 

pighian  cells;  sometimes,  especially  in  the  milium  of  cicatrices,  at 
the  expense  of  the  excretory  duct  of  the  suboriparous  glands." 
(Darter.)      For  treatment  see  page  130. 

SEBACEOUS    CYSTS. 

These  are  developed  in  the  obstructed  duct  of  a  sebaceous  gland. 
The  cyst,  during  its  development,  sometimes  attains  large  dimen- 
sions. A  depressed  spot  is  often  seen  on  the  surface,  obstructed 
by  a  brown  operculum  of  varying  size.  In  this  case  the  contents 
of  the  cyst  may  be  evacuated  by  pressure,  in  the  form  of  a  shiny 
yellow  worm,  which  when  dry  becomes  as  hard  as  stone.  After 
evacuation  the  cavity  of  the  cyst  contracts  gradually  without  treat- 
ment. 

WENS. 

Wens  have  a  predilection  for  the  scalp,  and  the  same  individual 
may  present  several  of  them.  They  enlarge  and  seem  to  multiply 
with  age.     They  appear  to  constitute  a  hereditary  deformity. 

According  to  some  authors,  they  are  retention  cysts,  i.e.,  large 
sebaceous  cysts.  This  view  is  supported  by  the  coexistence  on  the 
same  scalp  of  sebaceous  cysts,  with  visible  orifices,  and  wens  with 
no  orifice  which  can  be  seen.  According  to  others  they  are  dermoid 
cysts.  Darier  regards  them  as  a  variety  of  nsevi  with  cystic  follic- 
ular adenomata.  Possibly  all  three  theories  are  true  in  different 
cases. 

TRAUMATIC  EPIDERMIC  CYSTS. 

These  consist  of  small,  hard,  round,  indolent  tumours,  more  or 
less  movable  and  of  the  size  of  a  pea  or  a  small  nut.  They  result 
from  a  traumatism  having  caused  a  graft  of  epidermis  in  the 
deeper  tissues.  They  are  more  common  in  men  than  in  women 
(P-  373)- 

HYDROCYSTOMAS. 

These  are  multiple,  miliary  cysts  with  serous  contents,  occurring 
chiefly  on  the  face  in  women  of  middle  age.  whose  occupation 
exposes  them  to  the  heat  of  a  fire;  cooks,  washerwomen,  etc.    They 


TUMOURS    OF   THE    SKIN.  621 

may  disappear  in  winter,  to  reappear  and  multiply  in  summer.  They 
never  open  nor  suppurate.  The  superficial  skin  is  yellow  or  bluish 
grey.  They  appear  to  be  naevoid  in  nature;  cystic  sudoriparous 
adenomata. 

After  puncture  with  the  galvano-cautery  they  exude  a  drop  of 
clear  fluid  and  disappear,  generally  without  recurring. 

SYNOVIAL    CYSTS. 

I  mention  only,  by  the  way,  the  cysts  of  tendon  sheaths,  and  peri- 
articular cysts,  or  ganglions,  which  are  more  common  on  the  back 
of  the  wrist  than  elsewhere,  develop  slowly  and  remain  stationary, 
are  sensitive  to  pressure,  and  may  slightly  obstruct  the  movements 
of  the  subjacent  articulation. 

This  affection  belongs  to  surgery. 

HYGROMAS. 

Hygromas  are  formed  b}'  serous  effusion  into  the  pre-articular 
synovial  bursse  of  the  knee  and  elbow  and  may  occasionally  suppu- 
rate.   The  treatment  is  surgical.  ' 

MOLLUSCUM    CONTAGIOSUM. 

This  is  a  benign  dermatosis  occurring  at  all  ages  and  character- 
ised by  small,  soft,  superficial,  umbilicated  tumours,  apparently  hol- 
low, and  incompletely  filled  with  a  substance  which  can  with  diffi- 
culty be  expressed  between  the  nails.  These  small  tumours  are  of 
dimensions  varying  from  that  of  a  millet  seed  to  that  of  a  small 
cherry-stone.  They  are  common  on  regions  where  the  skin  is  thin ; 
the  eyelids,  breast  and  penis ;  and  on  the  seborrhoeic  regions,  the 
face,  bald  vertex,  medio-thoracic  regions,  etc.  In  some  cases  the 
elements  occur  in  great  numbers.  They  may  exist  in  all  sizes  in 
different  regions ;  at  other  times  the  eruption  is  discrete  and  com- 
posed of  a  few  scattered  elements. 

It  appears  certain  that  the  epithelial  tumour  which  constitutes 
each  element  of  molluscum  contagiosum  is  developed  from  the  epi- 
dermis and  not  from  a  sebaceous  gland.  It  consists  in  a  special 
and  characteristic  form  of  epidermic  degeneration. 


622  TUMOURS    OF    THE    SKIN. 

The  treatment  of  molluscuni  contagiosum  by  the  curette  is 
extremely  simple  and  gives  perfect  results.  If  the  elements  are  very 
numerous  the  treatment  may  be  carried  out  at  intervals. 

In  very  young  children  I  have  had  good  results  by  expression  of 
each  element,  followed  by  the  application  of  tincture  of  iodine. 


WARTS. 

Warts  are  benign,  contagious,  inoculable,  cutaneous  neoplasms, 
the  parasitic  cause  of  which  is  unknown.  Three  clinical  types  are 
distinguished;  the  common  wart,  the  flat  juvenile  wart,  and  the 
senile  or  seborrhoeic  wart. 

Common  Warts.  These  occur  in  both  sexes  at  all  ages  and  are 
especially  situated  on  the  exposed  parts ;  the  hands  and  fingers, 
around  the  nails  and  even  on  the  palm  of  the  hand.  They  are  too 
well  known  to  require  description. 

Flat  Juvenile  Warts.  These  always  occur  as  a  crop  of  small  flat 
papules,  wath  a  smooth  pink  surface,  disseminated  in  islands  or 


Fig.  221.     Common  Warts.      (Jacquet's   patient.      Photo   by   Dubray.) 

streaks  on  the  face  or  backs  of  the  hands.  By  their  small  size,, 
agglomeration  and  smooth  surface,  they  resemble  miliary  papular 
lichenoid  eruptions.     This  form  has  been  already  studied  (p.  119). 

Senile  Warts.  In  contrast  with  the  preceding,  senile  warts  occupy 
not  only  the  face  and  the  backs  of  the  hands,  but  chiefly  on  the 
trunk.  The_,'  may  attain  a  remarkable  degree  of  confluence,  and 
their  number  increases  with  age. 

Each  wart  forms  a  mammillated,  villous  projection,  appreciable  to. 
touch  even  when  minute. 


TUMOURS    OF    THE    SKIN.  623. 

The  colour  is  brownish  grey  or  green ;  the  surface  is  friable  and 
scraping  gives  rise  to  a  powder  of  epithelial  debris.     (Vide  p.  30.) 


PAPILLOMATA. 

Papillomata  occur  on  the  genital  organs  (vegetations)  ;  in  the 
mouth  in  the  same  form  (Dubreuilh)  ;  and  or  on  the  face  and  scalp. 
When  situated  on  the  mucous  membranes  they  appear  as  cauliflower 
growths ;  when  on  the  skin  as  an  agglomeration  of  hcffny  digitations. 

They  consist  of  small  benign  tumours,  of  long  duration  and  fre- 
quent recurrence,  apparently  inoculable,  or  at  any  rate  reinoculable 
in  the  patient;  they  may  be  scanty  and  disseminated,  on  the  hands, 
on  the  face,  and  on  the  scalp.  The}-  may  occur  conglomerated  on 
the  vulva  or  in  the  balano-preputial  furrows  and  form  large  masses. 

I  have  described  papillomata  elsewhere  (pp.  417  and  441),  and 
need  only  mention  here  that  they  always  consist  of  lesions  situated 
in  precise  localisations,  always  the  same,  and  without  any  tendency 
to  become  generalised.  Their  description  will  be  found  in  the 
regions  in  which  they  are  met  with. 

CYSTICERCUS. 

Cutaneous  cysticercus  is  a  rare  disease  and  is  due  to  the  intro- 
duction of  the  eggs  of  tcunia  solium  into  the  stomach,  to  the  migra- 
tion of  the  cysticercus  in  the  organism  and  to  the  formation  by  each 
of  them  of  a  small  cyst.  It  is  characterised  by  the  existence  of  small, 
painless  and  often  unnoticed  cysts  the  size  of  a  pea  or  small  nut, 
mobile  under  the  skin  and  of  slow  development.  The  diagnosis  is 
seldom  made  before  extirpation  and  examination  of  one  of  the  cysts. 

It  is  a  disease  to  be  remembered,  because  of  the  errors  in  diagnosis 
which  may  be  made  by  not  thinking  of  it.  Cutaneous  cysticercus 
presents  no  gravity,  but  the  migration  of  the  cysticercus  is  general 
and  special  cysts  may  develop  in  the  nerve  centres  or  the  eye  and 
cause  reactional  phenomena  corresponding  to  this  situation,  some  of 
which  may  be  fatal. 

HYPHOMYCOSIS    OF    RAMOND. 

I  have  studied  with  Beunnann  and  Rainond  a  hyphomycosis  very 
similar  to  cysticercus  and  characterised  by  a  series  of  small  round 


624  TUMOURS    OF   THE    SKIN. 

cysts,  underneath  the  skin,  the  size  of  a  nut  and  disseminated  all  over 
the  body.  The  cysts  contained  sero-purulent  fluid  and  recurred 
ill  situ  after  surgical  removal.  Culture  gave  pure  and  constant  colo- 
nies of  a  fine  fungus  of  still  undetermined  species. 

The  tumours  disappeared  under  the  internal  administration  of 
iodide  of  potassium.  After  three  months  a  fresh  tumour  appeared 
on  the  forehead,  which  also  disappeared  permanently  after  two  more 
months'  treatment. 

CALCAREOUS    SUB-CUTANEOUS    GRANULOMATA. 

This  is  a  rare,  rural  disease,  probably  parasitic  and  contagious, 
characterised  at  first  by  a  cold  sub-cutaneous  tumour,  resembling  a 
tuberculous  abscess,  with  an  indurated  base  of  stony  hardness,  and 
the  opening  of  which  evacuates  creamy  pus  full  of  calcareous  matter. 
Eventually  fresh  tumours  occur  at  a  distance,  and  after  some  months 
or  years  the  disease  becomes  generalised,  with  hectic  fever,  maras- 
mus and  death.  Treatment  consists  in  surgical  ablation  of  the 
tumours  when  possible. 

BLASTOMYCOSIS. 

The  blastomycoses  form  a  new  chapter  in  European  dermatology. 
They  appear  to  be  more  common  in  America  than  in  Europe,  where 
they  are  less  known  and  regarded  as  exceptional  cases. 

There  is  a  form  consisting  of  fungous,  lupoid,  vegetating  placards, 
and  frequently  mistaken  for  lupus. 

The  case  I  observed  resembled  a  gumma  of  the  tibia  and  was 
thought  to  be  tuberculous  by  some,  syphilitic  by  others.  Direct 
examination  and  culture  (Rubens-Duval)  shewed  it  to  be  caused 
by  a  yeast  with  a  dirty  yellow  culture. 

The  example  of  actinomycosis  should  always  suggest  internal 
treatment  by  iodide  of  potassium  without  neglecting  the  local  treat- 
ment. 

•  BOTRIOMYCOSIS. 

We  have  already  studied  botriomycosis  of  the  hand,  its  most  fre- 
quent situation  (p.  362).  It  always  occurs  in  the  form  of  a  fleshy 
framboesiform  bud  which  seems  united  to  the  subjacent  tissues,  but 


TUMOURS    OF    THE    SKIN.  625 

is  only  connected  to  them  by  a  thin  pedicle.  This  tumour,  which  was 
first  considered  specific,  appears  to  originate  like  the  fleshy  granu- 
lations of  wounds. 

Treatment  consists  simply  in  removal  and  cauterisation  with 
nitrate  of  silver. 

MULTIPLE    CHELOIDS. 

Cheloids  are  fibrous  tumours,  generally  elongated  but  of  various 
forms,  covered  with  normal  skin  and  united  to  it,  hard  to  the  touch 
and  formed  of  dense  and  resistant  tissue.  Generally  a  cheloid  fol- 
lows a  traumatism,  and  in  certain  subjects  all  traumatisms  give  rise 
to  a  cheloid  (the  so-called  cheloid  diathesis).  From  2  to  10  cheloids 
of  various  dimensions  may  be  seen  on  the  back,  chest,  face,  hands 
or  even  in  all  these  regions  at  the  same  time.  Their  development  is 
slow  and  progressive,  after  which  they  remain  stationary  and  do  not 
retrogress. 

The  tuberculous  nature  of  many  cheloids  is  beyond  question. 
Inoculation  in  the  guinea-pig  has  been  performed  repeatedly  and 
has  given  positive  results  in  a  great  number  of  cases. 

In  spite  of  a  few  successful  extirpations  of  cheloid,  it  is  necessary 
to  know  that  in  the  majority  of  cases  excision,  be  it  ever  so  complete, 
gives  rise  to  a  new  cheloid  larger  than  the  one  removed. 

The  only  satisfactory  treatment  consists  in  deep  linear,  quadrillar 
scarification  of  the  whole  tumour.  A  linear  injection  of  a  centi- 
gramme (1-7  grain)  of  cocaine  or  stovaine  is  made  under  the  cheloid 
three  minutes  before  the  scarification.  This  is  performed  with  a 
bistoury,  bearing  in  mind  that  the  depth  of  the  cheloid  below  the 
skin  is  equal  to  that  of  its  projection  above,  and  the  incisions  must 
be  made  through  the  whole  thickness. 

The  future  treatment  of  cheloids  should  be  radiotherapy,  applied 
in  the  same  doses  as  for  cancer  (p.  33).  It  appears  that  strong- 
applications  causing  erythema  give  more  rapid  results  with  cheloid, 
as  with  lupus  erythematosus. 

NAEVI. 

Under  the  name  of  A'ccz'i  should  be  understood  all  circumscribed 
cutaneous  deformities  (Brocq).  Na;vi  are  divided  into  classes  which 
are  very  distinct  objectively  and  histologically.    Moreover,  they  are 

40 


626 


TUMOURS    OF    THE    SKIN. 


the  origin  of  a  number  of  different  morbid  conditions,  so  that  a 
third  of  this  chapter  on  tumours  belongs  to  naevi  and  their  various 
derivatives. 

Pigmentary  nsevi  have  been  studied  with  the  melanodermias  (p. 
6ii).  Flat  vascular  naevi,  commonly  called  "port-wine  marks/' 
have  been  described  with  the  face  (p,  4). 

Tuberous  vascular  naevi  may  assume  the  form  of  veritable  tumours 
and  attain  an  extraordinary  size  (Fig.  222).  Their  colour  and 
appearance,  their  momentary  diminution  by  compression,  their  slow 


t'is.  222.     Naevus  with  tumours.      (Pboto  Dy  Norre.) 


Fig.  223.     Lymphangioma. 

(Besnier's   patient.      St.    Louis 

Hosp.    Museum,    No.    1466.) 


evolution,  their  congenital  origin  or  appearance  at  an  early  age.  con- 
stitute the  diagnosis. 

\'ascular  lymphatic  naevi  or  lyinpliaiii^ioinata  may  occur,  like  the 
angiomas,  in  placards  or  in  the  form  of  tumours. 
,     They  practically  always  occur  on  a  pre-existing  naevus,  which  has 
existed  for  years.    On  this  is  slowly  developed  a  mammillated  tumour 
which  is  formed  of  large  conglomerated  papules.     The  latter  arise 


TUMOURS  OF  THE  SKIN.  627 

in  a  kind  of  large,  soft  vesicle  which  opens  and  disappears.  In  its 
place  a  new  induration  is  formed  which  becomes  projecting.  The 
mass  is  of  soft  consistency  and  a  characteristic  sign  is  the  presence 


Tig.  324,     Generalised    molluscuin    with    pigmentary    spots. 
(Pean's  patient.     St.   Louis  Hosp.   Museum,   No.   361.) 

of  yellow  lymph  which  can  be  made  to  exude  from  many  points  by 
pressure. 

There  are  no  functional  symptoms ;  the  duration  is  indefinite,  with 
slow  increase  in  size.    The  treatment  is  the  same  for  nxw\. 

Tuberous  nsevi,  hairy  or  non-hairy,  occur  in  all  localisations  and 
in  all  sizes  and  shapes,  and  need  not  detain  us  here. 

SOFT  CUTANEOUS  FIBROMATA,     MOLLUSCUM. 

Soft  cutaneous  fibromata  are  special  forms  of  naevi  arising  in  the 
thickness  of  the  skin  with  the  form  of  a  small  soft  mass  which  seems 
to  project  through  the  cuticle  in  the  dermis.  The  mass  gradually 
becomes  pendulous  and  pedunculated:  iiiolhisciiin  petiduliiin.  Like 
Uc'evi,  these  small  benign  tumours  are  often  multiple  on  the  same  sub- 
ject. The  deformity  is  consanguineous  and  hereditary.  Treatment 
consists  in  removal  with  scissors  or  the  galvano-cautery, 

NEURO-FIBROMATOSIS   OF   RECKLINGHAUSEN. 

This  rare  general  dystrophy  is  characterised :  ( i )  by  mucous 
tumours  of  the  preceding  type,  disseminated  over  the  whole  body; 


628 


TUMOURS    OF   THE    SKIN. 


(2)  by  fibrous  tumours  arising  from  the  connective  tissue  of  nerves; 

(3)  by  hyperpigmentary  melanodermic  spots.  It  is  a  congenital, 
consanguineous  disease,  associated  with  deficient  mental  develop- 
ment. 


Fig.  225.     Symmetrical   hyperkeratotic    naevi. 
(Besnier's  patient.      St.   Louis   Hosp.   Museum,   No.    1680.) 


WARTY    NAEVI. 

Warty  nsevi  may  be  soft  or  hard ;  the  latter  bemg  more  frequent 
and  more  characteristic.  They  form  flattened  projections  with  clear 
borders,  in  absolute  contrast  to  the  neighbouring  skin,  by  their  grey,, 
yellow  or  brown  colour,  by  the  grey  hyperkeratosis  of  their  surface 
and  by  their  linear  or  geographical  distribution.  The  diagnosis  pre- 
sents no  difficulty. 

Treatment  is  generally  nil,  for  they  remain  stationary  without 
increasing.  When  treatment  is  required  it  should  be  bipolar  elec- 
trolysis (p.  5). 


SYMMETRICAL   NAEVO-ADENOMATA    OF   THE   FACE. 

I  have  described  these  with  the  aflfections  of  the  face  (p.  107) .   They 
are  small,  soft  tumours,  miliary,  or  as  large  as  a  pea,  conglomerated 


TUMOURS    OF    THE    SKIN. 


629 


in  the  naso-genial  furrow,  the  glabella  or  the  chin.     They  are  naevi, 
and  their  congenital  origin  has  often  been  proved.     However,  they 


Fig.  226,    "Warty   naevus. 
(Besnier's  patient.      St.    Louis   Hosp.    Museum,   No.    1478.) 

seldom  develop  till  the  age  of  14  or  15  years,  and  when  once  devel- 
oped remain  stationar}-.  They  are  more  common  in  females.  When 
destroved  bv  the  sralvano-cauterv  thev  never  recur. 


630  TUMOURS    OF    THE    SKIN. 

HYDRADENOMATA. 

Hydradenomata  are  small  papular  miliary  tumours  of  the  neck, 
the  anterior  thoracic  region  and  the  root  of  the  arms ;  they  are  more 
rare  in  other  regions,  such  as  the  eyelids,  forehead,  nose  and  ears. 

The  distribution  of  the  elements,  regularly  disseminated,  resembles 
that  of  several  papular  exanthems.  Each  element  is  from  2  to  3  mil- 
limetres in  diameter,  oval  in  form,  of  a  yellowish  red  colour,  of  firm 
consistency,  and  covered  by  the  normal  skin. 

Their  growth  and  multiplication  are  slow,  and  when  they  have 
reached  3  millimetres  in  size  they  remain  stationary  without  modifi- 
cation, degeneration,  or  glandular  affection.  They  seem  to  consist 
of  cysts  developed  on  the  embryonic  germs  of  sudoriparous  glands. 
According  to  this  view  they  are  another  form  of  iicrvns. 


PIGMENTARY    URTICARIA. 

Pigmentary  urticaria  is  a  chronic  disease  which  commences  during 
the  first  year  by  eruptive  crops  of  urticarial  elements.  These  ele- 
ments remain  papular,  become  pigmented  and  remain  stationary 
without  alteration.  It  is  a  generalised  disease  afifecting  the  whole 
surface  of  the  body  and  is  undoubtedly  connected  with  multiple 
naevi. 

This  morbid  type,  which  may  be  consanguineous,  is  constituted, 
in  the  mature  state,  by  flat  nodosities,  sometimes  intensely  congested, 
generally  greyish  brown,  chronic,  permanent,  and  characterised 
anatomically  by  an  infiltration  of  special  connective  tissue  cells 
known  as  mast  cells.  The  clinical  description  will  also  be  found  on 
page  558. 

DERMATOMYOMA. 

This  is  a  rare  affection  described  by  Bcsnicr,  and  is  peculiar  to 
women.  It  commences  in  the  form  of  small,  lenticular,  rose-coloured 
spots,  which  gradually  become  papular.  These  papules  occupy  a 
whole  region  in  groups  or  streaks.  They  may  be  dull  red,  or  of  the 
same  colour  as  the  skin.  They  are  composed  of  intersecting  muscu- 
lar fasciculi  in  the  dermis.  The  compression  which  these  fasciculi 
exerts  on  the  nerve  endings  gives  rise,  under  the  influence  of  exter- 


TUMOURS    OF    THE    SKIN.  631 

nal  stimulus,  to  crises  of  unendurable  pain,  requiring  surgical  inter- 
vention, but  otherwise  without  gravity.  These  tumours  are  probably 
of  nsevoid  origin  and  never  recur. 


DERMOID    CYSTS. 

Dermoid  cysts  originate  from  the  inclusion  of  an  epidermic  fold 
in  an  embryonic  cleft.  They  are  only  found  in  regions  where  these 
clefts  have  existed ;  the  line  of  the  eyebrow,  the  lateral  parts  of  the 
neck,  the  sacro-coccygeal  and  uro-genital  grooves.  They  exist  at 
birth,  but  do  not  develop  till  puberty  or  adult  age.  Their  only  treat- 
ment, when  this  is  required,  is  surgical  extirpation. 

CALCAREOUS    TUMOURS. 

Calcareous  tumours  of  the  skin  may  be  calcified  adipose  lobules, 
true  osteomas,  calcification  of  fibromas,  wens,  dermoid  cysts  and 
epitheliomas. 

There  is  an  ossifying  sarcoma  which  gives  rise  to  sub-ungual  exos- 
tosis of  the  toes.  Usually  these  calcareous  tumours  of  the  skin  are 
phleholiths^  or  the  calcareous  transformation  of  the  walls  of  a  vein 
after  local  phlebitis. 

HARD    CUTANEOUS    FIBROMAS. 

Hard  cutaneous  fibromas,  the  prototypes  of  benign  connective 
tissue  tumours,  are  usually  multiple,- of  different  sizes,  the  size  of  a 
pea  or  nut,  hard,  and  mobile  under  the  skin,  or  with  it.  Usually^ 
when  once  formed  they  persist  without  change. 

LIPOMAS. 

Lipomas  are  tumours  formed  of  adipose  tissue.  They  may  remain 
solitary,  varying  in  size  from  a  nut  to  the  foetal  head.  Sometimes, 
after  a  few  years  enormous  sub-cutaneous  lipomas  of  variable  sizes 
develop  in  crops,  and  may  become  innumerable. 

They  are  benign  but  troublesome,  and  their  surgical  removal  may 
be  necessary  in  certain  cases.    The  symmetrical  adeno-lipomatosis  of 


(532  TUMOURS    OF    THE    SKIN. 

Launois  and  Bcnsaitdc  is  a  rare  affection,  characterised  by  the  pro- 
(hiction  of  enormous  masses  occupying  the  neck,  nape,  axillae,  or 
inguinal  folds ;  in  fact  all  the  regions  which  present  lymphatic  glands. 


XANTHOMA. 

Xanthoma  is  a  benign  neoplastic  disease  of  unknown  cause,  with 
constant  specific  lesions  which  may  aft'ect  the  viscera,  but  of  which 
the  dermatological  history  is  the  chief  one. 

The  anatomical  characteristic  of  this  disease  is  the  formation  of 
agglomerations  of  xanthelasmic  cells  in  the  organs  or  in  the  dermis ; 
these  are  enormous  adipose  connective  tissue  cells  filled  with  proto- 
plasmic granulations.  The  evolution  of  these  agglomerations  is 
generally  slow,  and  when  once  formed  they  persist  without  retrogres- 
sion. 

Objectively,  the  lesions  of  xanthoma  may  be  flat,  tuberous  or  in 
tumours. 

(i)  The  flat  lesions  are  level  with  the  skin,  without  projecting 
from  its  surface.  They  consist  of  miliary  spots,  or  spots  the  size  of 
a  lentil  (p.  557),  more  rarely  placards  from  half  an  inch  to  an  inch 
or  more  square. 

(2)  The  tuberous  lesions  project  from  the  skin  for  3/  to  i  milli- 
metre. They  have  the  same  divers  dimensions  as  the  preceding, 
but  are  generally  very  small. 

(3)  The  tumour  lesions  may  attain  the  size  of  a  nut.  They  gen- 
erally co-exist  with  the  tuberous  forms,  of  which  they  are  only  the 
development,  and  are  usually  scanty  among  the  more  abundant  but 
less  prominent  lesions.  All  the  xanthelasmic  infiltrations,  whatever 
form  they  assume,  are  invariably  of  soft  consistency. 

Xanthoma,  whether  flat,  tuberous  or  in  tumours,  may  be  localised 
or  generalised.  When  localised,  which  is  more  common,  it  infiltrates 
the  eyelids  (p.  130).  It  may,  without  generalisation,  affect  several 
dift'erent  localisations,  for  instance  the  elbows  and  knees  (p.  289)  ; 
when  generalised  it  occupies  the  whole  body,  with  a  predominance  at 
the  points  of  friction  and  on  the  buttocks.  It  forms  a  multitude  of 
miliary  lesions  of  all  forms,  generally  small.  Those  on  the  back  of 
the  fingers  and  the  folds  of  the  fingers  are  very  characteristic. 

Generalised  xanthoma  is  accompanied  by  visceral  xanthelasmic 
infiltrations,  especially  of  the  liver,  causing  chronic  icterus  (from  2 


TUMOURS    OF   THE    SKIN.  6^3 

to  7  years),  and  a  form  of  icterus  without  icteric  urine  and  without 
coloration  of  the  sclerotics,  called  xanthochromia. 

There  may  be  generalised  xanthoma,  with  icterus,  without  icterus, 
with  xanthochromia,  or  with  icterus  followed  by  xanthochromia. 
In  the  last  case  the  biliary  pigments  appear  to  exist  in  the  serum 
and  not  to  filter  through  the  kidney. 

Xanthoma,  even  when  generalised,  is  not  accompanied  by  general 
phenomena.  The  lesions  arise  in  crops,  which  do  not  retrogress 
when  once  produced.  This  permanence  is  characteristic  of  true 
xanthoma. 

No  general  treatment  appears  to  favourably  modify  xanthoma. 
External  treatment  is  useful  for  the  removal  of  disfiguring  lesions 
and  consists  in  galvano-puncture  at  intervals  of  2  to  3  millimetres. 
These  punctures  leave  no  mark,  and  the  lesions  disappear  after  one 
or  two  applications.  I  have  practised  this  treatment  of  xanthoma 
for  7  or  8  years,  without  it  having  been  generally  adopted  in  derma- 
tological  practice.    The  results,  however,  have  always  been  excellent. 

Diabetic  Xanthoma.  This  may  be  a  true  xanthoma,  of  which  gly- 
cosuria is  an  accessory  cause,  or  a  xanthelasmiform  diabetide.  The 
question  is  still  doubtful ;  but  it  is  certain  that  it  is  a  transient  affec- 
tion (Besjiier),  in  which  it  differs  considerably  from  the  characters 
of  true  xanthoma.    The  symptoms  are  also  different. 

The  localisation  on  the  extremities,  the  elbows  and  knees  and  not 
on  the  eyelids,  the  rapid  appearance,  the  inflammatory  symptoms 
which  accompany  its  florid  forms,  the  hypersemia  of  the  placards 
and  tumours,  which  may  even  sometimes  become  exulcerated,  the 
usual  retrogression  after  a  few^  months,  all  form  a  special  entity; 
although,  anatomically,  ordinary  xanthoma  and  diabetic  xanthoma 
resemble  each  other. 

Diabetic  xanthoma  has  been  attributed  to  xanthoma  of  the  pan- 
creas (Hallopeait).  but  the  glycosuria  always  precedes  the  eruption, 
and  the  eruption  may  disappear  while  the  glycosuria  continues. 

SARCOMAS    IN    GElSFERAL. 

Sarcomas  are  all  malignant  neoplasms,  the  elements  of  which  are 
of  connective  tissue  origin.  There  are  three  dermatological  types: 
(i)  the  multiple  pigmentary  sarcoma  of  Kaposi;  (2)  the  generalised 
hypodermic   sarcoma  of  Perrin;    (3)    the   melanotic   supernjevoid 

sarcoma. 


634  TUMOURS    OF    THE    SKIN. 

There  are  also  the  simple  sarcomatous  tumours,  of  malignant  but 
variable  evolution,  with  indifferent  primary  and  secondary  cutaneous 
localisation. 

A  primary  cutaneous  sarcoma  may  occur  with  fusiform  cells,  or 
a  lympho-sarcoma  formed  of  adenoid  tissue,  which  may  be  primary 
or  secondary. 

MULTIPLE  PIGMENTARY   SARCOMATOSIS   OF  KAPOSI. 

This  commences  on  the  feet  and  hands  in  the  form  of  congestive, 
cedematous  hard  patches  (macular  stage)  ;  or  by  the  immediate 
formation  of  tumours,  the  size  of  a  millet  seed  or  a  pea,  always  pur- 
ple or  black  (neoplastic  stage).  They  multiply  quickly,  and  slowly 
increase  in  size,  covering  the  extremities  and  becoming  more  scanty 
at  the  roots  of  the  limbs  and  on  the  trunk.  When  they  are  very 
numerous  the  skin  between  them  is  hard,  thickened  and  infiltrated. 
These  tumours  always  increase  in  number  and  usually  in  size,  but 
some  become  absorbed,  leaving  a  cicatrix,  while  others  appear.  The 
disease  becomes  generalised  in  2  to  20  years,  and  the  general  health 
remains  good  for  a  long  time. 

There  is  no  subjective  symptom,  such  as  pain  or  pruritus,  and  no 
functional  symptom  except  weakness  of  the  fingers.  But  the  tumours 
develop  on  the  mucous  membranes  and  viscera,  giving  rise  to 
cachexia  and  general  phenomena  of  fever  and  diarrhcea.  and  the 
patient  dies  of  marasmus.     The  treatment  is  only  symptomatic. 


GENERALISED    HYPODERMIC    SARCOMATOSIS    OF    PERRIN. 

This  affection  consists  in  the  formation,  without  systematic  locali- 
sation, on  the  trunk,  face  and  roots  of  the  limbs,  of  multiple  tumours, 
causing  a  visible  projection,  or  perceived  ony  by  palpation,  the  size 
of  a  cherry  stone  or  a  nut,  at  first  free  under  the  skin,  and  colourless, 
afterwards  adherent  to  the  skin,  which  becomes  red  or  purple. 
Towards  the  end  of  the  disease  some  of  the  tumours  may  ulcerate. 

The  disease  progresses  rapidly,  and  new  tumours  are  seen  at 
each  examination  Asthenia  and  cachexia  develop  rapidly  with 
symptoms  depending  on  visceral  generalisation,  and  death  super- 
venes from  10  to  15  months  after  the  onset  of  the  disease.  There 
is  no  satisfactory  treatment. 


TUMOURS    OF    THE    SKIN.  635 

MELANOTIC   SUPER-NAEVOID    SARCOMA. 
(NAEVO-CARCINOMA    OF    UNNA.) 

This  develops  on  a  congenital  naevus,  usually  pigmentary,  in 
the  form  of  a  black,  indolent  tumour,  which  is  slowly  extensive 
and  may  remain  stationary  for  years.  After  this  indefinite 
period,  which  is  shortened  by  local  intervention,  follows  a 
period  of  very  rapid  generalisation  in  the  skin  and  viscera. 
Cachexia  increases  from  day  to  day,  and  death  follows.  The 
secondary  tumours  may  assume  considerable  dimensions,  or  re- 
main small,  or  some  may  retrogress  and  disappear,  or  become 
ulcerated.  The  cause  of  this  process  is  unknown  and  the  treat- 
ment is  nil. 

SECONDARY  CUTANEOUS  SARCOMATOSIS. 

A  sarcoma  may  develop  in  any  part  of  the  body  apart  from  the 
skin  ;  in  the  soft  part  of  any  region,  and  becomes  fixed  to  the  skin 
and  ulcerate,  or  develop  underneath  it.  A  generalised  cutaneous 
sarcomatosis  may  follow,  with  all  the  characters  of  the  primary 
hypodermic  sarcomatosis  of  Perrin. 


PRIMARY     SARCOMA    OF    THE    SKIN. 

A  sarcomatous  tumour  of  the  spindle-celled  type  may  arise  on 
any  part  of  the  skin ;  on  the  finger,  wrist,  forehead,  arms  or  foot. 
The  grave  neoplastic  nature  of  these  tumours  is  usually  recog- 
nised without  histological  examination,  but  not  always,  and  its 
exact  nature  should  be  confirmed  by  histological  examination. 

LYMPHADENOMA. 

Lyphadenoma,  of  glandular  structure,  is  generally  developed 
at  the  expense  of  a  lymphoid  organ  (tonsils,  thymus,  lymphatic 
glands)  ;  the  cutaneous  localisations  are  secondary,  but  not  con- 
stant. 

There  is  a  primary  lymphadenoma  of  the  skin.  Its  initial  lesion 
has  all  the  characters  of  an  epidermised  indurated  chancre  under- 


636 


TUMOURS    OF    THE    SKIN. 


going  retrogression,  but  having  preserved  its  cartila-ginous  in- 
duration. Around  the  primary  lesion  are  often  situated  3  or  5 
other  similar  smaller  lesions,  all  of  the  hardness  of  india-rubber. 
The  surface  of  the  lesion  may  become  exulcerated. 

These  lesions  may  be  mistaken  for  indurated  chancres,  tuber- 
culous lymphangitis,  or  glanders,  and  are  rarely  diagnosed  with- 
out a  biopsy. 


Fig.  227.     Fibrosarcoma   of    the    foot. 
(Morestln's  patient.     St.   Louis  Hosp.   Museum,   No.    2099.) 


This  lymphadenonia  invades  the  corresponding  glands,  and  the 
neoplastic  development  in  these  may  progress  more  rapidly  than 
in  the  primary  tumour. 

Radiotherapy  in  high  doses  (30  to  50  units  H.  in  sittings  of  5 
units  each,  at  intervals  of  18  days)  has  arrested  the  development 
of  the  initial  lesions  in  a  case  of  this  kind,  but  has  not  prevented 
the  propagation  to  the  glands. 


TUMOURS    OF    THE    SKIN.  637 

MYCOSIS    FUNGOIDES. 

Mycosis  fungoides  should  be  placed  by  the  side  of  the  sar- 
comas, but  separate  from  them,  in  spite  of  the  connection  with 
sarcoma  held  by  the  German  School ;  for  clinical  experience 
shews  that  this  special  nosographical  type,  although  it  allows 
a  comparison  of  mycosis  fungoides  with  sarcoma,  does  not  per- 
mit them  to  be  confounded. 

Mycosis  fungoides,  so  named  by  Alibert,  is  a  neoplastic  disease 
of  unknown  cause,  almost  exclusively  localised  to  the  skin,  of 
chronic  and  benign  course,  as  compared  with  that  of  cancer,  with 
paroxysms  and  retrogressions,  but  often  ending  in  death.  Its 
evolution  may  be  divided  into  four  periods : — the  period  of  simple 
pruritus ;  the  period  of  eczematisation ;  the  period  of  infiltration  ; 
and  the  period  of  tumours ;  but  this  division  is  schematic,  and  the 
succession  of  periods  is  not  constant.  There  are  even  cases  of 
tumours  arising  from  the  first  {Vidal,  Brocq).  I  shall  describe 
an  average  case. 

(i)  It  commences  at  about  the  40th  year  with  progressive 
pruritus,  at  first  without  visible  lesions.  This  pruritus  is  parox- 
ysmal, but  the  intervals  of  remission  are  rare,  and  the  pruritus, 
at  these  times,  diminishes  only,  without  disappearing.  It  grad- 
ually increases  and  may  become  intense.  It  is  usually  general- 
ised, but  more  marked  in  the  sacral  regions,  in  the  flanks  and  in 
the  folds  of  flexion. 

(2)  After  some  months  or  years  of  this  pruritus  without 
lesions,  the  scratching  produces  irregular  patches  of  eczemati- 
sation, but  sometimes  with  sharply  defined  borders,  often  very 
red  (premycotic  erythrodermia),  and  bearing  between  them 
islands,  with  well  defined  borders  and  an  absolutely  healthy  sur- 
face. These  eczematous  patches  have  different  fates ;  some- 
times they  are  transient  and  alter  their  situation,  sometimes  they 
remain,  and  a  diffuse  progressive  infiltration  is  slowly  produced 
underneath  them. 

(3)  The  transition  from  the  second  to  the  third  period  is 
gradual.  Under  the  influence  of  pruritus  and  eczematisation, 
the  skin,  especially  in  regions  where  it  is  thin,  becomes  thick- 
ened, infiltrated  and  permanently  red.  At  the  same  time  all  the 
groups  of  glands  increase  in  size,  becoming  visible  under  the  skin 
and  painful  to  palpation.     This   infiltration  may  be  diffuse,  or 


638  TUMOURS    OF    THE    SKIN. 

form  patches  of  different  sizes  enclosing  islands  of  normal  skin. 

(4)  At  this  period  there  frequently  occur  at  distant  points,  on 
the  pre-existing  diffuse  infiltration,  bosses  or  projections  in  the 
form  of  semi-circles,  or  serpiginous.  The  regions  where  these 
mycotic  tumours  most  often  develop  are  the  face,  the  roots  of 
the  limbs,  the  flanks  and  breasts.  The  disease  at  this  fourth 
period  often  passes  through  two  stages ;  one,  during  which  the 
tumours  are  localised ;  the  other,  in  the  course  of  which  they 
become  disseminated. 

The  tumours,  of  the  size  of  a  small  nut  or  chestnut,  after- 
wards take  the  form  and  dimensions  of  a  tomato.  The  surface 
presents  an  umbilication  from  which  radiate  furrows,  dividing 
the  bossy  projections.  The  umbilication  soon  becomes  ulcerated, 
fungous  and  sloughing,  and  the  edge  of  the  ulcer  remains  sloping. 
These  multiple  tumours,  agglomerated  in  heaps,  or  scattered  over 
large  surfaces,  may  remain  almost  equal ;  some  of  them,  on  the 
contrary,  may  attain  enormous  dimensions  and  weigh  several 
pounds. 

A  peculiarity  of  mycosis  is  that  these  neoplastic  formations 
cause  very  little  alteration  in  the  general  health  of  the  patient, 
who  may  live  for  months  without  suffering. 

Another  peculiarity  of  mycosis,  which  is  rare  in  the  history  of 
neoplastic  diseases,  is  that  in  many  cases  tumours  the  size  of 
an  orange  may  rapidly  retrogress  and  disappear,  without  leaving 
any  trace,  except  the  cicatrix  of  the  ulcer  which  they  bore  on 
the  summit.  These  remissions  may  take  place  in  individual 
tumours  or  on  all  of  them  equally,  and  in  a  few  months  the 
disease  retrocedes  by  several  years.  But  this  is  unfortunately 
not  the  rule;  more  often  new  outbreaks  of  pruritus,  infiltration 
and  tumours  form  again,  and  the  ground  gained  is  lost.  The 
disease  thus  left  to  itself  leads  to  death  in  3  to  10  years.  In  all 
the  cases  I  have  examined  death  was  caused  by  streptococcus  in- 
fection, and  this  fact  requires  to  be  verified ;  the  infection  hav- 
ing been  produced  sometimes  by  multiple  abscesses,  sometimes 
by  purulent  pleurisy. 

Anatomically,  this  disease  is  characterised  by  an  infiltration  of 
round  cells,  having  the  characters  of  lymphocytes  in  a  young 
state.  They  occur  in  the  dermis  in  a  reticulated  lymphatic  tissue 
of  new  formation.  They  are  found  as  intra-epidermic  agglom- 
erations in  the  first  periods  of  the  disease.     This  fact  is  absolutely 


TUxMOURS    OF    THE    SKIN.  639 

characteristic  and  often  confirms  a  doubtful  diagnosis  by  a 
biopsy,  the  importance  of  which  for  the  patient  is  obvious. 

This  disease,  probably  of  parasitic  origin,  does  not  appear  to 
be  hereditary  or  contagious.  Cases  appear  now  to  be  a  little 
more  numerous,  but  are  far  from  common. 

After  a  period  during  which  the  therapeutics  of  mycosis 
appeared  to  be  absolutely  nil,  radiotherapy  in  some  hands,  espe- 
cially on  a  case  of  Brocq  and  Bisserie,  appears  to  have  given 
admirable  results.  It  caused  disappearance  of  the  pruritus,  the 
infiltration  and  the  tumours,  and  appeared  to  lead  to  cure  of  the 
disease.  The  future  will  reveal  if  these  cures  are  permanent. 
The  rules  of  radiotherapy  for  mycosis  seem  to  be  the  same  as 
for  other  tumours  (25-30  units  H,  in  5  or  6  successive  sittings, 
with  intervals  of  15-20  days).  The  first  result  obtained  will 
guide  the  operator.  The  applications  should  be  made  without 
a  diaphragm  and  always  on  the  largest  extent  of  surface  possible. 

CUTANEOUS  LYMPHADENIA. 

This  affection  is  a  form  of  glandular  lymphadenia  with  cutane- 
ous lesions.  The  cervical,  axillary  and  inguinal  glands  are 
enormously  enlarged  and  form  prejecting  masses  under  the 
skin. 

At  the  same  time  cutaneous  lesions  occur,  more  frequent  and 
more  pronounced  on  the  face  than  elsewhere.  There  is  a  thick- 
ening of  the  region,  due  to  a  more  or  less  hard  or  flabby  oedema, 
of  a  purple  colour,  on  which  appear  tumours  of  various  sizes  and 
rounded  contours,  the  size  of  a  cherry,  almond  or  nut ;  sometimes 
so  numerous  as  to  touch  each  other.  Analogous  lesions  occur 
on  the  extremities. 

The  diagnosis  of  these  glandular  masses  is  confirmed  by 
examination  of  the  blood,  which  shows  a  leukaemia  of  the  lym- 
]3hatic  type.  The  prognosis  is  fatal  and  there  is  no  treatment. 
However,  we  must  remember  that  radiotherapy  of  the  spleen 
and  glandular  masses  may  restore  the  hsematological  standard  in 
a  few  hours.     But  the  matter  requires  further  study. 

EPITHELIOMAS. 

On  the  skin,  as  in  all  parts  of  the  body,  epitheliomas  are  malig- 
nant neoplasms.     It  is  first  necessary  to  mention  the   long  benig- 


640  TUMOURS    OF    THE    SKIN. 

nity  of  certain  epitheliomas  localised  to  the  superficial  layers  of 
the  skin. 

Epithelioma  commences  between  the  ages  of  40  and  50,  and  is 
more  common  in  men,  and  on  the  face.  Skin  which  becomes 
prematurely  senile,  either  spontaneously,  or  in  men  exposed  by 
their  occupation  to  inclement  weather,  is  predisposed  to  epithelio- 
matous  vegetations.  Cicatrices,  especially  those  of  chronic 
ulcers,  are  still  more  so.  Epitheliomas  may  be  secondary  to  pre- 
cancerous diseases.  Xeroderma  pigmentosum  (p.  6),  senile  con- 
crete seborrhoea  (p.  31),  buccal  leucoplasia  (p.  39)  ;  also  secondary 
to  the  chronic  ulcerations  of  lupus  and  syphilis,  and  to  the  con- 
genital malformations,  naevo-carcinomas   (p.  635). 

Clinically,  we  can  distinguish  cases  in  which  epithelioma  forms 
a  single  lesion  and  cases  where  there  is  disseminated  epithelio- 
matosis.  Further,  it  is  necessary  to  distinguish  the  superficial 
epithelioma,  which  is  benign  for  a  time ;  from  deep  epithelioma, 
which  is  always  grave.  Darier  describes  four  anatomical  and 
clinical  forms  of  epithelioma. 

( 1 )  A  papillary  form,  in  which  the  lesion  is  constituted  by  warty, 
agminated  papilliform  projections,  with  a  raised  border  and 
sloping  margin.  This  is  generally  situated  on  the  lips,  cheeks, 
eyelids,  chin,  tongue,  hands  and  glans  penis.  It  is  a  neoplasm 
which  remains  superficial  for  a  long  time,  is  slow  in  evolution 
at  first,  but  more  active  in  advanced  stages. 

(2)  A  second  form  is  common  cancroid,  which  occurs  on  the 
lips,  tongue,  and  buccal  mucous  membrane,  and  includes  super- 
cicatricial  epitheliomas.  Objectively  it  is  a  grey  tubercle  cov- 
ered with  a  crust.  Later  on  it  forms  a  tumour  the  size  of  half 
a  nut  enclosed  in  the  skin.  The  borders  are  purple  and  over- 
hang a  punched  out,  sinous  ulceration.  The  lymphatic  glands 
are  affected  early  and  the  cancerous  ulceration  becomes  deep, 
sphacelated,  and  suppurative.  Cachexia  is  rapid  and  death  super- 
venes, hastened  by  haemorrhages. 

The  pearly  epithelioma  is  a  benign  and  immobile  form  of  this 
variety. 

(3)  The  third  form.  Hat  superficial  epithelioma  of  the  nose  and 
eyelids,  is  more  chronic,  without  extension  to  the  glands  and 
without  generalisation.  It  remains  stationary  for  15  to  20  years 
and  is  characterised  by  a  flat,  superficial,  pink,  vascularised 
cicatrix,  bordered  by  a  thin  serpiginous  crust,  which  covers  small 


TUMOURS    OF   THE   SKIN. 


641 


ulcerations.  The  active  element  of  the  disease  is  the  grey- 
granulation,  the  peripheral  multiplication  of  which  causes  and 
enlarges  the  lesion,  which  becomes  cicatricial  later. 

(4)  Rodent  ulcer  appears  to  be  an  ulcerative  variety  of  the  pre- 
ceding.    It  occurs  on  the  forehead,  nose  and  eyelids.     In  this 

form  the  neoplasm  is  almost 
invisble  and  the  lesion  is 
formed  chiefly  by  the  chron- 
ic ulcer.  The  base  of  the 
ulcer  is  dry,  pink  or  yellow. 
The  ulcer  is  sharply  cut  on 
one  side  and  has  a  slightly 
inclined  cicatrix  on  the 
other.  Its  local  malignancy 
is  great ;  its  general  malig- 
nancy nil. 

Diffuse  epitheliomatosis  of 
the  face,  which  may  follow 
concrete  sebaceous  acne, 
"senile  scum,"  etc.,  is  only 
a  clinical  form  and  does  not 
belong  to  a  single  and  con- 
stant anatomical  type. 

Very    distinct     from     the 
naevo-adenomas  of  the  face 
ns.  228.      super-seborrhoeic    Epitheiiotnat-     ^rc  the  truc  adenomas  of  the 

osis.      Besnier's    patient.      St.    Louis    Hosp.         d-iti  •      fViof      io      +/-.      citr      +1-.^ 
Museum,    No.    1194.)  bKm  ,      tOdt      IS      lO      Say      tnc 

epithelial  neoplasms  with  glandular  structure  and  benign  evo- 
lution. 

The  latter  resemble  sebaceous  cysts  or  indifferent  tumours  and 
vary  in  size  from  a  nut  to  a  small  orange.  The  skin  on  their 
surface  is  normal,  they  are  of  more  or  less  firm  consistence,  their 
surface  is  regular,  they  are  not  painful  and  never  infect  the 
glands.     The  treatment  consists  in  total  surgical  ablation. 

These  epitheliomas  of  adenoid  structure  have  not  a  clinical  evo- 
lution exactly  corresponding  to  their  structure,  and  are  only  an 
anatomical  species.  There  are  epitheliomas  of  this  form  which 
sometimes  become  calcified,  and  afterwards  arrested  in  their  evo- 
lution. 


41 


642  TUMOURS    OF    THE    SKIN. 

The  skin  may  present  secondary   carcinomas,  consecutive  to  a 


Fig.  229.     Cylindromas.      (Poucet's    patient.      Drawing   by    Lolson.) 

primary  lesion   of  the  breast   for  example.     These  may  occur   in 
the  form  of  tumours  or  in  plateaus. 

CYLINDROMAS. 


Under  the  name  of  cylindromas  are  designated  neoplasms 
which  arc  usually  benign,  exceptionally  malignant;  hereditary, 
consanguineous,  chiefly  localised  on  the  face  and  scalp,  more 
rarely  on  the  back  and  limbs,  and  more  common  in  women  of 
middle  age.  The  tumour  is  at  first  hard,  indolent,  and  of  slow 
growth ;  it  remains  single  for  a  long  time  and  does  not  usually 


TUMOURS    OF    THE    SKIN.  643 

recur  after  removal.  After  a  time,  secondary  tumours  are 
formed  around  the  first,  and  end  by  covering  the  whole  scalp. 
Tufts  of  hair  emerge  between  them,  and  give  the  patient  a 
peculiar  appearance  (Fig.  229).  These  tumours  are  as  large  as 
nuts  or  chestnuts,  sessile  or  pedunculated.  Histologically  they 
consist  of  an  alveolar  epithelioma,  with  myxomatous  invasion. 

The  prognosis  is  benign,  and  surgical  excision,  if  possible  be- 
fore the  multiplication  of  the  tumours,  is  the  best  treatment.  It 
is  a  rare  disease,  for  which,  to  my  knowledge,  radiotherapy  has 
not  been  attempted. 


Leprosy    .    .    .    .  p.  655 


CHRONIC  INFECTIOUS  DERMATOSES. 

In  this  chapter  will  be  considered  the  symptoms,  course  and 
evolution  of  the  four  great  chronic  infections  dermatoses,  in- 
cluding what  is  known  of  their  treatment. 

Syphilis,  many  manifestations  of  zvhich  zue  have"] 

studied  in  the  course  of  this  volume,  will  be  />re- I  Syphilis P- 644 

sented   as   briefly   as   possible | 

A    general   sketch    will    be    given    of   cutaneous^ 
tuberculosis  and  of  the  divers  tuberculides,  recog-  LTuberculosis    .    .   p.  652 
nised  as  such  up  to  the  present J 

Leprosy,  not  being  a  disease  of  our  country,  has- 
not  taken  a  part  in  this  book  proportional  to  its 
value  in  general  nosography ;  hence  the  resume 
which  we  shall  give  will  be  a  little  less  concise  than 
the  preceding 

Human  glanders,  being  a  rarity,  will  only  be  (^c-^ 
corded  a  few  lines J  .    .    .    .  p.    oy 

SYPHILIS. 

Syphilis  is  a  specific,  contagious,  inoculable,  and  therefore 
microbial  disease,  but  of  which  the  microbial  cause  remains  so 
far  unknown.^     Its  spontaneous  propagation  is  only  seen  in  the 

1  Translator's  Note.  Since  the  above  was  written,  Schaudinn  and 
Hoffmann  described  a  special  form  of  Spirochete  found  in  secondary 
syphilitic  lesions  and  in  the  juice  from  the  syphilitic  glands.  This  has 
been  named  the  Spirochete  pallida,  to  distinguish  it  from  the  Spirochate 
refringens  a  larger  and  more  common  form  of  spirillum  which  is  found 
in  lesions  which  are  not  syphilitic.  The  Spirochcete  pallida  is  an  extremely 
delicate  organism,  almost  transparent  and  actively  mobile.  It  is  long 
and  spiral  with  pointed  extremities.  Its  length  varies  from  4  to  140, 
and  its  breadth  is  almost  immeasurable.  The  number  of  spirals  varies 
from  6  to  14,  and  these  are  sharper  and  narrower  and  more  numerous 
than  in  the  case  of  Spirochete  refringens.  The  spirochaete  pallida  is  much 
more  difficult  to  stain  than  the  5".  refringens,  but  may  be  stained  with  a 
solution  of  azure  blue  in  alcohol,  mixed  with  eosin.  The  organism  has 
also  been  found  by  Metchinkoff  in  syphilitic  lesions  in  monkeys.  Also 
Metchinkoff  has  examined  Scha  dinn's  preparations  and  concludes  that 
they  are  identical  with  the  spirochaete  found  in  the  monkeys.  S.  pallida 
has  also  been  found  in  the  lesions  of  congenital  syphilis  by  Levaditi.  It 
therefore  appears  that  this  organism  is  more  likely  to  be  the  true  microbe 
of  syphilis  than  any  others  which  have  formerly  been  described  and  the 
results  of  further  researches  will  be  awaited  with  interest.  (Vide  Dcut. 
Med.  IVoch.,  May  4;  Gazette  dcs  Hopitcaux,  May  18;  Semaine  Medicale, 
May  17;  La  Syphilis,  June,  iQOS-) 


CHRONIC    INFECTIOUS    DERMATOSES.  645 

human  species,  but  it  has  been  experimentally  inoculated  in  certain 
species  of  monkeys.  Its  symptoms,  lesions,  and  evolution  in  man 
are  characteristic  and  of  great  importance.  I  shall  first  study  the 
objective  signs  and  lesions  in  the  order  of  their  appearance. 

(i)  The  first  lesion  is  the  hard  chancre  (infecting  chancre,  initial 
sclerosis,  initial  lesion),  which  arises  at  the  point  of  inoculation, 
generally  from  15  to  20  days  after  it,  occasionally  later.  It  forms 
a  superficial  exulceration,  slightly  depressed,  non-exudative  and 
of  fleshy  colour,  around  which  is  formed  in  one  or  two  weeks  a 
characteristic,  cartilaginous,  cardboard  like,  induration.  The  exul- 
ceration varies  from  5  to  10  millimetres  in  depth.  The  chancre, 
after  a  period  of  increase  of  2  or  3  weeks,  remains  stationary  and 
always  heals  spontaneously,  the  exulcerated  surface  becoming  epi- 
dermised  in  4  or  5  weeks.  The  induration  disappears  in  a  few 
months,   but   remains   perceptible    for   a   long  time. 

The  indurated  chancre  is  generally  single,  but  this  rule  presents 
many  exceptions. 

(2)  The  second  lesion  of  syphilis  is  the  satellite  gland  of  the 
chancre.  This  is  an  almost  painless  adenitis  causing  enlarge- 
ment of  the  gland  above  the  size  of  an  almond,  and  india-rubber 
hardness.  The  gland  affected  is  that  corresponding  to  the  region 
cf  the  chancre.  This  adenitis  is  perceptible  from  the  first  week 
of  the  chancre  and  attains  its  maximum  when  the  retrogression 
of  the  chancre  commences.  The  indicator  gland  is  often  recog- 
nisable six  months  or  more  after  the  infection. 

(3)  The  glands  in  its  neighbourhood  are  affected  in  their  turn 
and  their  assemblage  constitutes  the  pleiades.  All  of  them  shew 
the  characters  of  the  adenitis  just  described,  but  the  glands 
of  the  pleiades  are  only  half  the  size  of  the  satellite  gland  of  the 
chancre.  Syphilitic  glands  never  suppurate ;  but  mixed  chancres 
occur,  a  symbiosis  of  the  microbe  of  chancroid  and  the  syphilitic 
virus,  the  indicator  gland  of  which  may  suppurate.  Such  cases 
are  exceptional.  The  mixed  chancre  presents  usually  the  ulcera- 
tion and  suppuration  of  soft  chancre  and  the  induration  of  the 
specific  chancre. 

(4)  The  pleiades  is  not  long  isolated,  and  all  the  glands  of  the 
subject  become  affected  one  by  one,  and  constitute  in  10  to  15 
months  the  generalised  poly-adenitis  of  secondary  syphilis. 

(5)  The  syphilitic  roseola  appears  on  the  flanks,  the  chest,  the 
trunk  and  limbs  about  70  to  80  days  after  infection.     The  eruption 


646  CHRONIC    INFECTIOUS    DERMATOSES. 

varies  in  distinctness,  is  painless  and  consists  of  rose-coloured 
macules,  the  size  of  the  end  of  the  little  finger.  The  skin  is  speckled 
and  the  roseola  may  be  discrete  or  confluent.  It  may  easily  escape 
notice,  but  may  be  accompanied  in  a  few  days  by  slight  transient 
fever.  The  roseola  may  disappear  in  15  days  or  remain  stationary 
for  3  months  or  more.  It  is  often  accompanied  by  headache,  espe- 
cially nocturnal  (secondary  headache)  and  osteocopic  pains  in  the 
tibiae,  which  may  occur  with  phenomena  of  slight  painful  periostitis. 
After  the  roseola  the  secondary  period  commences,  and  is  char- 
acterised by  lesions  of  which  generalisation  on  the  whole  surface 
of  the  body  is  the  chief  characteristic. 


Fig.  230.     Florid    papular    eruptio;i    of   secondary    syphilis. 
(Halopeau's   patient.      St.    Louis    Hosp.    Museum,    No.    2022.> 


(6)  There  is  generally  a  papular  eruption  formed  of  round,  raised 
papules  of  a  reddish  brown  or  copper  colour,  with  a  scurfy  ring 
round  them  {collarette  of  Biet).  They  may  be  very  scanty  (10  to 
15)  or  occur  in  thousands.  Their  dissemination  is  remarkable,  and 
they  may  be  found  on  the  eyelids  and  on  the  palm  of  the  hand.  As  a 
rule  they  do  not  ulcerate  and  disappear  after  a  time  varying  from 
I  to  6  weeks.  They  may  become  eroded  in  intertriginous  regions, 
causing  the  so-called  cutaneous  mucous  patches.  In  malignant 
syphilis  they  enlarge,-  become  ulcerated  and  covered  with  crusts  con- 


CHRONIC   INFECTIOUS   DERMATOSES.  647 

stituting  syphilitic  ecthyma,  or  the  old  syphilitic  rupia.     Such  cases 
are  rare. 

(7)  At  the  same  time  that  papules  develop  on  the  skin  mucous 
patches  occur  on  the  mucous  membranes.  These  also  may  be  scanty 
or  mutltiple.  They  are  seen  on  the  genital  organs,  the  anus  and 
especially  in  the  buccal  cavity,  where  they  occupy  the  pillars  of  the 
fauces,  the  soft  palate,  tongue,  floor  of  the  mouth,  and  the  internal 
surface  of  the  lips  and  cheeks.  They  consist  of  red,  oval  exulcera- 
tions,  several  millimetres  in  diameter,  with  a  grey  border.  The 
eruption  of  these  patches  is  not  uniform,  but  occurs  in  sub-involutive 
crops,  the  first  of  which  are  the  most  acute,  and  which  may  last  for 
months  with  remissions.  The  mucous  patch  is  the  lesion  from  which 
most  fresh  cases  of  syphilis  proceed,  for  it  is  more  contagious  than 
the  chancre. 

In  rare  cases  the  patches  are  so  large  and  so  numerous  that  symp- 
toms of  angina  may  occur,  with  dysphagia,  etc. ;  and  if  the  larynx 
is  afifected  at  the  same  time,  with  aphonia.  Mucous  patches  never 
ulcerate  and  never  leave  cicatrices,  and  disappear  after  a  time  like 
the  secondary  papules  of  the  skin. 

(8)  The  preceding  lesions  constitute  the  secondary  period,  and 
to  them  must  be  added  alopecia  in  patches,  which  occurs  from  the 
5th  to  the  8th  month  and  affects  the  scalp,  eyebrows  and  even  the 
hairs  of  the  body. 

Iritis  is  more  rare ;  it  may  occur  at  an  early  period,  but  is  gener- 
ally later  than  the  papules  or  mucous  patches. 

Onyxis  occurs  also  at  the  same  date.  This  always  affects  several 
fingers,  generally  laterally.  At  first  it  resembles  a  painless  whitlow, 
hut  the  lesion  is  always  dry  and  exfoliates  without  suppurating. 

After  the  secondary  period,  which  is  nearly  always  vigorously 
treated,  there  is  generally  a  period  of  quiescence  between  the  sec- 
ondary lesions,  which  are  almost  inevitable,  and  the  tertiary  lesions 
which  may  be  most  often  avoided  by  correct  treatment. 

Tertiarism  is  very  distinct  from  secondary  syphilis.  It  is  prac- 
tically never  characterised  by  generalised  eruptions  or  lesions,  but 
by  limited  regional  eruptions  and  strictly  localised  lesions.  On  the 
other  hand  the  multiformity  of  its  lesions  is  almost  indefinite. 

(9)  The  lesions  of  the  skin  include  papular  or  papulo-tnhercular 
syphilides,  in  circles  or  in  corymbs  or  in  large  figured  designs,  and 
gummatous  placards,  forming  chronic  crusted  lesions,  commonly 
called  teritiary  serpiginous  syphilides,  which  may  be  ulcerated  or 


64&  CHRONIC   INFECTIOUS   DERMATOSES. 

not.     These  superficial  gummata  constitute  the  tertiary  syphiHtic 
ulcer  of  the  leg. 

(lo)  Along  with  these  superficial  lesions  there  are  others  which 
constitute  deep  syphilomas  or  gummata,  neoplastic  at  first,  which 
undergo  a  necrotic  evolution  or  progressive  sclerosis.  They  may 
develop  under  the  skin,  in  the  muscles  or  in  any  organ. 

The  sclero-gummatous  lesions  of  the  tongue,  and  choroido-retin- 
itis  of  the  eye  are  of  the  same  date;  also  the  bony  perforations  of 
the  nose  and  sequestra.  All  the  tertiary  lesions  may  occur  from  i8 
months  to  20  years  or  more  after  the  chancre.  The  further  they  are 
removed  from  the  initial  period  the  more  scarce  are  the  lesions,  but 
without  any  certainty  that  they  will  not  return. 

(11)  Syphilis  of  the  nerve  centres.  A  large  number  of  nervous 
diseases,  formerly  classed  as  autonomous,  appear  now  as  the  sequelae 
of  syphilis,  and  nearly  all  originate  in  perivascular  sclerotic  lesions. 
They  may  be  explained  as  follows :  In  the  secondary  period  a  num- 
ber of  transient  lesions  are  produced,  slightly  congestive,  but  without 
very  marked  functional  symptoms.  Each  of  these  later  on  gives  rise 
to  a  nucleus  of  sclerosis  constricting  the  nerve  cells  or  fibres.  These 
lesions  may  be  dispersed,  forming  sclerosis  in  patches;  or  they  may 
be  diffused  in  the  vessels  of  the  pia-mater,  forming  general  paralysis; 
or  they  may  be  systematised  in  nerve  tracts,  forming  locomotor 
ataxia  and  progressive  muscular  atrophy. 

These  lesions  manifest  themselves  long  after  they  are  formed, 
which  explains  the  mediocrity  of  the  results  obtained  by  treatment. 

(12)  Hereditary  Syphilis.  Syphilis  is  one  of  the  rare  infectious 
diseases,  the  transmission  of  which  by  both  parents  to  the  child  is 
the  rule,  when  the  parents  are  in  a  state  of  active  syphilis.  It  seems 
that  this  transmission,  which  may  be  from  either  the  father  or 
mother,  may  take  place  at  two  periods  and  furnish  different  clinical 
pictures.  If  the  contamination  occurs  during  the  first  months  of 
pregnancy  the  foetus  is  generally  killed.  No  disease  causes  so  many 
still-births  and  miscarriages.  It  is  at  this  point  that  4  or  5  mis- 
carriages almost  certify  syphilis  in  the  genitors.  Some  infected 
infants  escape  death  and  are  born.  These  are  cachectic  during  the 
first  months  of  existence  and  seem  to  float  in  their  super-abundant 
skin.  They  have  the  appearance  of  little  old  men.  They  may  pre- 
sent specific  secondary  eruptions ;  their  development  is  deficient,  and 
most  often  they  die  at  an  early  age.  The  survivors  form  dwarfs, 
curiosities,  hydrocephalic  children  wath  enormous  foreheads,  chil- 


CHRONIC   INFECTIOUS   DERMATOSES.  649 

dren  with  a  projecting  lower  jaw,  the  prognathism  of  which  causes 
a  crescent-shaped  profile.  As  they  have  few  symptoms  of  their 
origin  which  are  recognisable,  the  aiTections  have  been  attributed  to 
many  diseases  of  which  the  primary  origin  was  not  recognised. 
(See  hcrcdo-syphilitic  alopecia,  p.  222.) 

On  the  other  hand  the  child  may  have  been  healthy  at  conception 
and  infected  in  the  latter  months  of  pregnancy  by  an  intercurrent 
syphilis  of  the  mother.  In  this  case  it  may  have  been  born  appa- 
rently healthy  and  present,  after  a  few  weeks  of  normal  existence 
all  the  symptoms  of  florid  secondary  syphilis  with  aflfection  of  the 
general  health.  These  sucklings  may  die  of  syphilis,  more  often 
than  the  preceding,  generally  from  some  inteixurrent  accessory 
affection,  such  as  broncho-pneumonia  or  erysipelas. 

Lastly,  the  child  may  be  born  non-syphilitic,  i.e.,  presenting  an 
active  lesion  of  s\philis,  but  showing  dystrophic  changes  in  the 
skeleton ;  platycnemic  tibia ;  maxillary  and  dental  lesions,  etc.,  bear- 
ing witness  to  the  morbid  condition  of  its  genitors.  These  dystro- 
phic stigmata  lead  to  interesting  retrospective  diagnosis. 

Among  heredo-syphilitics  there  are  thus  the  infected  who  have 
true  syphilis,  and  the  dystrophic  who  have  only  the  mark  of  the 
paternal  or  maternal  syphilis ;  but  the  latent  infection  may  manifest 
itself  at  the  age  of  10  or  20,  or  later,  by  ulcerative  or  necrosing 
lesions,  which  are  often  mistaken  for  dystrophies,  and  the  nature  of 
which  is  often  not  recognised. 

Hygiene  of  syphiliiics.  All  the  primary  or  secondary  ulcerations 
of  syphilis  are  contagious,  and  it  is  often  difficult  to  determine  the 
secondary  contagious  or  the  tertiary  non-contagious  (?)  nature  of 
certain  lesions  (see  tertiary  sclerosing  glossitis  p.  48).  The  dis- 
infection of  external  ulcerations  is  hence  the  rule,  and  the  prohibi- 
tion of  all  mediate  (razors,  brushes,  etc.),  and  immediate  contacts. 
The  latter,  especially  kissing  and  coitus,  are  the  most  dangerous, 
and  for  a  long  period.  Even  after  several  months,  any  trace  of  ero- 
sion on  the  genital  organs  should  forbid  coitus.  Marriage,  with  the 
unanimous  consent  of  all  syphilographers,  should  be  delayed  for  4 
or  5  years.  If  syphilis  has  been  contracted  in  the  course  of  marriage, 
by  extra-conjugal  intercourse,  sexual  connection  between  the  mar- 
ried should  be  immediately  stopped.  If  both  conjoints  are  syphilitic 
they  should  abstain  from  all  reproductive  coitus.  If  fecundation 
occurs  the  mother  must  receive  intensive  antisyphilitic  treatment, 
even  if  the  father  only  is  syphilitic,  and  if  the  mother  does  not  appear 


650  CHRONIC   INFECTIOUS   DERMATOSES. 

to  be  contaminated ;  for  a  syphilitic  infant  may  be  begotten  by  a 
syphilitic  father  and  an  apparently  healthy  mother.  This  infant  may 
be  suckled  by  its  mother  without  contaminating  her,  proving  that 
the  mother  is  syphilised  (  ?)  or  vaccinated  (  ?).     (Colles  lazv.) 

The  child  of  a  person  with  active  syphilis  should  thus  be  regarded 
as  syphilitic.  It  may  be  suckled  by  the  mother  even  when  she  is 
supposed  to  be  healthy,  but  cannot  be  given  to  a  non-syphilitic  nurse 
(Colles  lazv). 

Treatment  of  syphilis  in  the  adult.  Syphilis  may  be  treated  by 
internal  medicaments  such  as :  pills  of  proto-iodide  ( ^  grain,  i  to  3 
daily)  ;  Dnpnytren's  pills  (i  to  2  daily) ^;  liquor  of  Van  Swieten^; 
I  or  2  tablespoons  daily.  Or  by  cutaneous  inunction  of  double  mer- 
curial ointment,^  60  to  75  grains  a  day,  applied  alternately  in  the 
different  folds  of  the  flexion.  The  inunction  is  applied  at  night,  after 
a  previous  soaping  and  the  application  washed  off  in  the  morning. 
Salivation  and  infection  of  the  gums,  causing  stomatitis,  must  be 
watched  for.  These  forms  of  treatment  may  be  necessary  owing 
to  the  distance  of  the  physician,  the  nervousness  of  the  patient,  etc. 
Necessity  of  concealment  may  require  the  inunction  to  be  made 
during  the  day  on  the  soles  of  the  feet,  and  washed  off  at  night. 

The  most  rational  and  scientific  treatment  is  that  by  injections 
{Scarenzio).  This  is  made  at  fixed  periods  and  allows  the  intro- 
duction into  the  economy  of  a  known  quantity  of  the  drug,  without 
causing  unnecessary  intestinal  trouble.  A  great  number  of  different 
salts  and  compositions  have  been  recommended.  Some  recommend 
soluble  and  others  insoluble  preparations.  Most  of  the  soluble  salts 
should  be  injected  frequently  and  in  small  doses;  the  insoluble  salts 
in  larger  doses  and  at  longer  intervals,  which  makes  them  more  prac- 
ticable :  but  they  may  give  rise  to  more  prolonged  phenomena  of 
intoxication. 

The  following  are  three  types  of  solutions  for  injection: — 

(i)  Biniodide    of   mercery   ....  "1 

T    J.J        r       J-  r         10  centigrammes. 

Iodide   of   sodium J  *= 

Sterilised   distilled   water   ...    aa  10  cubic  centimetres. 

1  Translator's  Note.  Dupuytren's  pill  contains :  Perchloride  of  mer- 
cury, gr.  1/5  to  1/4;  extract  of  opium,  gr.  1/4  to  1/2;  guiacum  resin,  gr.  4. 
Ricord's  Proto-iodide  pill  contained:  Proto-iodide  of  mercury,  gr.  5/6; 
extract  of  opium,  gr.  1/1;  extract  of  guiacum,  gr.  i  2/3.  (Ricord.  Traite 
des  IMal.  Ven.) 

2  Solution  of  perchloride  of  mercury,  i  to  1000. 

3  The  unguentum  Cincreum  used  in  England  consists  of  i  part  of  mer- 
cury, I  part  of  lanoline,  and  ^  part  of  olive  oil. 


CHRONIC    INFECTIOUS   DERMATOSES.  651 

N.  B. — The  distilled  water  may  be  replaced  by  normal  saline  solu- 
tion. A  cubic  centimetre  of  the  injection  contains  i  centigramme  of 
biniodide  (gr.  1-7),  corresponding  to  4  milligrammes  of  mercury 
(gr.  1-17). 

The  average  efficacious  dose  is  from  2  to  2^  centigrammes  of 
biniodide  (about  gr.  1-3).  From.  2  to  5  centigrammes  (gr.  2-7  to 
5-7)  or  more  of  biniodide  may  be  dissolved  to  the  cubic  centimetre 
(m.  17),  with  an  equal  quantity  of  iodide  of  sodium.     (Lafay.) 

(2)  Grey  oil  contains  40  per  cent,  of  mercury. 

Purified   mercury 40  grammes 

Sterilised    lanoline 12         " 

Sterilised  vaseline 13  " 

Sterilised   oil   of  vaseline 35  " 

Injections  are  made  weekly  with  Barthelemy's  syringe  half  full, 
or  3  to  4  divisions  of  Pravas  syringe:  equivalent  to  8  to  10  centi- 
grammes of  mercury  (gr.  i  1-7  to  i  yy). 

(3)  Injections     of     calomel :     For     this     purpose     sublimed 
calomel  is  suspended  in  sterilised  olive  oil. 

Weekly  injections  of  5  centigrammes  of  calomel  (gr.  5-7)  are 
made,  except  under  special  circumstances. 

The  injections  are  made  in  alternate  buttocks.  (For  technique  see 
page  513.)  A  pregnant  syphilitic  woman  should  be  treated  as  if 
she  was  not  pregnant.  In  the  treatment  of  a  woman  apparently 
healthy  hut  pregnant  by  a  syphilitic  husband,  injections  of  8  centi- 
grammes (gr.  I  1-7)  of  grey  oil  may  be  practised  once  a  month. 

The  treatment  of  the  syphilitic  child  may  be  carried  out  by  the 
same  methods ;  altering  the  dose  according  to  age.  A  suckling  may 
take  from  20  to  50  drops  a  day  of  liquor  Van  Swieten,  in  three  or 
four  doses  After  two  years  a  teaspoon  daily.  It  may  also  be  treated 
by  inunctions  of  15  to  30  grains  of  mercurial  ointment,  according 
to  age. 

The  treatment  of  syphilis  of  the  nervous  system,  which  is  always 
unavoidably  too  late,  should  be  practised  by  injections  in  large  doses 
(Leredde),  but  generally  gives  mediocre  results. 

The  treatment  of  late  hereditary  syphilis,  like  that  of  a  severe 
syphilis,  in  the  opinion  of  all  authors,  requires  almost  exclusively 
the  employment  of  injections  of  large  doses.    (Barthelemy,  Leredde.) 

Duration  of  Treatment.  The  first  treatment  should  last  18  months, 
whatever  the  method  employed.     This  period  includes  intervals  of 


6S2  CHRONIC    INFECTIOUS    DERMATOSES. 

rest.  The  patient  is  treated  20  days  in  the  month,  and  rests  for 
one  month  out  of  three. 

During  the  whole  duration  of  treatment,  including  the  periods  of 
rest,  the  patient  should  take  15  grains  a  day  of  chlorate  of  potash, 
which  is  considered  to  be  an  antidote  to  the  mercury  and  a  precaution 
against  accidents.  This  drug,  no  more  than  any  other,  should  not 
be  prescribed  blindly  or  indefinitely ;  nor  should  its  action  be  regarded 
as  decisive.  During  4  years  specific  treatment  should  be  resumed  at 
intervals;  as  a  precautionary  measure,  it  is  recommended  for  one 
month  every  year. 

There  should  be  no  hesitation  in  treating  malignant  forms  of 
syphilis  more  actively  and  for  longer  periods;  for  the  lesions  are 
apt  to  recur  and  difficult  to  disperse.  Syphilographers  of  all  coun- 
tries have  now  a  tendency  to  advise  more  active  treatment,  with 
larger  doses  and  for  longer  periods,  than  they  did  ten  years  ago. 

TUBERCULOSIS. 

Tuberculosis  is  a  specific  contagious  disease,  inoculable  in  man 
and  most  animals,  sometimes  but  very  rarely  hereditary,  and  caused 
by  the  bacillus  of  Koch. 

The  history  of  visceral  tuberculosis  has  been  long  in  becoming 
known,  and  is  probably  still  incomplete.  The  dermatological  his- 
tory of  tuberculosis  is  made  slowly,  and  still  presents  numerous 
obscurities. 

A  tuberculous  product  containing  bacilli,  when  it  is  inoculated  on 
the  skin,  usually  determines  an  anatomical  tubercle,  a  raised  hyper- 
trophic lesion  with  a  wrinkled  and  condylomatous  surface,  of  chronic, 
progressive  evolution  and  rarely  presenting  a  tendency  to  ulceration 
(p.  336).  The  tuberculous  lesion  of  inoculation  generally  causes  an 
adenitis.  It  develops  chronically,  but  may  end  in  glandular  soften- 
ing and  chronic  ulceration. 

The  adenitis  generally  becomes  multiple  and  one  or  two  glands 
only  become  suppurative  (cold  abscess),  causing  chronic  ulceration. 
Sometimes  a  polyadenitis,  formerly  called  scrofulous,  becomes  more 
or  less  generalised  without  any  tendency  to  softening,  and  remains 
chronic  without  modification. 

The  lesions  and  their  adenitis  have  variable  situations  according 
to  the  point  of  entry.  A  pharyngeal  origin  causes  tuberculous 
adenitis  of  the  neck,  formerly  called  "King's  Evil,"  as  infection  by 


CHRONIC   INFECTIOUS   DERMATOSES.  65.3 

the  respiratory  tract  causes  pulmonary  tuberculosis,  and  by  the  diges- 
tive tract,  intestinal  ulcerations,  etc. 

Tuberculosis  may  develop  locally,  whatever  its  type,  place  of  ori- 
gin or  localisation.  But  it  may  also  give  rise  to  bacillary  dispersions, 
which  may  in  their  turn  become  malignant  or  benign.  We  must  here 
set  aside  all  visceral  and  articular  tuberculosis  and  limit  ourselves 
exclusively  to  the  dermatological  tuberculous  lesions. 

These  are  divided  into  two  groups.  In  the  first  are  included 
lesions  of  which  the  tuberculous  origin  is  undoubted,  because  their 
inoculation  in  the  guinea-pig  produces  tuberculosis.  In  the  second 
are  included  lesions,  clinically  shewn  to  be  connected  with  lesions 
known  to  be  tuberculous,  but  of  which  inoculation  in  the  guinea-pig 
does  not  cause  tuberculosis. 

The  first  group  have  been  named  tuberculides  and  the  second 
toxi-tuberculides  (Hallopeou),  but  the  latter  name  formulates  a 
hypothesis  which  has  not  been  demonstrated  experimentally.  It  is 
better  to  call  the  lesions  experimentally  shewn ,  to  be  tuberculous, 
tuberculoses,  and  the  others  tuberculides,  leaving  the  latter  with  the 
original  signification  given  to  it  by  Darier.  Moreover,  there  are 
points  of  transition  between  the  two  classes  which  have  not  yet  been 
sufficiently  studied  by  experiment. 

There  are  cutaneous  or  mucous  tuberculous  ulcerations  of  the 
skin  and  of  the  pharyngeal,  lingual,  buccal,  and  anal  mucous  mem- 
branes described  previously,  the  bacillary  nature  of  which  is  gen- 
erally easy  to  demonstrate. 

There  are  sub-cutaneous  nodules  opening  on  the  skin  and  con- 
stituting a  deeper  tuberculous  ulceration  than  the  preceding. 

There  are  cutaneous  superficial  nodules  in  placards,  eroding  the 
skin  and  very  suppurative  {Gaucher),  ending  also  in  chronic  ulcera- 
tion of  the  surface.  These  two  lesions  generally  arise  from  the  sup- 
puration of  a  subjacent  adenitis,  followed  by  development  of  the 
tuberculous  infection  round  the  fistulous  orifice  of  the  surface  of  the 
skin.  Generally,  direct  inoculation  of  the  skin  causes  the  anatomical 
tubercle  in  its  primary  form,  or  the  development  which  constitutes 
vegetating  or  warty  tuberculosis  (Riehl  and  Paltauf,  p.  336). 

Tuberculous  lupus  results  from  the  nodular  intradermic  evolution 
of  tuberculosis,  but  the  bacilli  becomes  scarce,  although  it  is  gen- 
erally inoculable  in  the  guinea-pig.  The  evolution  is  slow,  progres- 
sive and  may  be  ulcerative,  or  vegetating,  but  lupus  often  does  not 


6S4  CHRONIC    INFECTIOUS    DERMATOSES. 

ulcerate  at  all  and  extends  without  changing  its  type  of  evolution 
in  the  form  of  a  chronic  cutaneous  infiltration. 

There  is  a  lesion  homologous  with  tuberculous  lupus,  which  gives 
a  negative  inoculation  in  the  guinea-pig.  This  is  the  sarcoid  of 
Boeck. 

After  lupus  should  be  placed  the  true  cheloids,  of  which  the  tuber- 
culous nature,  without  being  absolutely  constant,  seems  to  be  con- 
firmed, at  least  in  a  number  of  cases  (p.  394).  These  are  hard, 
fibrous  tumours,  rounded  or  linear,  generally  post-traumatic,  some- 
times Spontaneous,  of  slow  development  and  indefinite  persistence 
in  situ. 

There  is  a  whole  series  of  tuberculides  which  present  characters 
of  diflfusion,  analogous  to  those  of  secondary  syphilitic  eruptions. 
They  do  not  seem  in  general  to  be  inoculable  in  the  guinea-pig.  How- 
ever, they  have  given  positive  results  according  to  some  authors. 

The  first  type  of  these  is  lichen  scrofulosorum  (p.  503),  an  erup- 
tion formed  by  groups  of  round,  yellow,  miliary  papules  scattered 
over  the  whole  body.  The  structure  of  these  lesions  suggest  tuber- 
culosis, and  even  the  name  indicates  the  clinical  connection  of  this 
eruption  with  tuberculosis.  A  florid  form  may  be  connected  with 
this,  the  agminated  papido-pustnlar  eruption,  of  chronic  evolution 
described  by  Hallopeau  and  Thibierge. 

The  second  type  of  tuberculides  with  generalised  eruption  is  con- 
stituted by  the  papido-tubercidous  tuberculides  with  cicatricial  evo- 
lution, described  by  Brocq  and  Barthelemy  (acnitis,  folliclis),  at 
first  as  folliculitis  under  different  names,  and  by  others  as  acne 
cachecticorum  or  scrofulosorum  (p.  338). 

With  the  punctiform  eruptive  tuberculides  must  be  placed  the 
eruptive  tuberculides  in  placards.  The  type  of  these  is  found  in 
fixed  lupus  erythematosus  (p.  18),  the  tuberculous  nature  of  which 
was  first  maintained  by  Besnier,  and  especially  the  mobile  erythema- 
tous lupus  or  exanthematoid  {Brocq). 

Close  to  the  latter  may  be  placed  lupus  and  erythema  pernio 
(p.  335).  Some  add  to  this  list  the  erythema  induratum  of  Bacin, 
that  is  to  say,  erythema  nodosum ;  others  the  angiokeratoma  of  Mi- 
belli.  But  the  latter  connections  are  uncertain  and  based  on  clinical 
relationships  which  are  less  evident  and  less  definite  than  those  which 
have  placed  the  preceding  forms  among  the  tuberculides. 

Lastly  a  pseudo-xanthelasmic  lesion  has  been  reported  in  the 
course  of  tuberculous  cachexia,  elastorrhexis,  which  causes  the 


CHRONIC    INFECTIOUS   DERMATOSES.  653 

disappearance  in     places  of  the  elastic  tissue  of  special  linese  albi- 
cantes   (Bodin). 

There  is  no  specific  treatment  for  tuberculosis,  in  its  divers 
dermatological  and  other  forms.  Treatment  varies  with  the 
localisations  and  has  been  studied  with  them. 

LEPROSY.(i) 

Leprosy  is  a  chronic  contagious  disease,  inoculable  from  man 
to  man,  but  peculiar  to  the  human  species,  caused  by  a  specific 
bacillus  discovered  by  Hansen.  Its  inoculation  in  the  monkey 
has  just  been  confirmed   (Nicolle). 

This  disease,  one  the  most  ancient  known,  still  occurs  endem- 
ically  over  an  immense  surface  of  the  earth ;  nearly  the  whole  of 
Asia,  the  borders  of  Africa,  the  coast  of  the  Mediterranean,  trop- 
ical America,  and  in  Europe,  the  Scandinavian  peninsular.  In 
France  only  rare  and  sporadic  cases  are  seen,  of  which  many 
authors  have  even  disputed  the  authority,  and  authentic  cases 
coming  from  foreign  countries ;  from  our  Colonies  in  Asia,  The 
Antilles  or  Guiana.  Owing  to  the  rarity  of  cases  seen  in  France, 
I  shall  condense  in  short  paragraphs  the  history  of  a  disease 
which  is,  however,  of  capital  importance  in  many  countries. 

We  are  ignorant  of  the  usual  mode  of  entry  of  the  virus  ;  it  may 
possibly  be  by  the  nasal  fossae.  The  incubation  of  the  disease 
may  be  from  a  few  months  up  to  5  years  or  more ;  in  the  last  case 
it  must  be  admitted  that  some  focus  exists  at  some  part  of  the 
body,  which  remains  latent  without  multiplying  or  dispersing. 
Among  the  premonitory  symptoms,  chronic  coryza  has  been  said 
to  be  frequent. 

Nothing  certain  is  known  till  the  appearance  of  the  leprous 
roseola,  an  exanthematous  eruption  of  irregular  rose  coloured 
maculae,  varying  in  number  and  in  rate  of  evolution.  This  erup- 
tion is  characteristic.  After  this  the  disease  may  evolve  accord- 
ing to  two  different  types ;  tubercular  leprosy,  or  ancesthetic  leprosy. 
These  may  coexist  in  the  form  of  mixed  types,  but  are  usually 
well  defined. 

Tubercular  Leprosy.  The  eruption  may  be  schematically 
divided  into  three  periods  (Leloir)  ;  the  period  of  eruption,  the 
neoplastic  period,  and  the  ulcerative  period. 

1  This  chapter  has  been  m-uch  inspired  by  the  remarkable  works  of 
Jeanselme  on  this  subject. 


6s6  CHRONIC    INFECTIOUS    DERMATOSES. 

Period  of  eruption.  The  hypersemic  macules  of  the  eruption 
appear  successively,  become  more  and  more  infiltrated  and 
papular,  thickened,  organised  and  projecting.  These  tubercles 
appear  more  or  less  quickly,  successively  or  by  crops,  in  a  few 
months  or  years ;  they  also  vary  in  number  and  are  more  or  less 
limited  or  diffuse. 

Neoplastic  period.  ^  The  tubercles  evolve  towards  gummy  trans- 
formation and  ulceration  in  florid  leprosy,  at  least  in  countries 
where  the  disease  is  endemic.  In  France,  the  tubercles  often 
evolve  towards  retrogression  and  cicatrisation  without  ulcerating. 
But  this  retrogression  is  very  slow.  Certain  tubercles  disap- 
pear while  others  arise.  On  the  face  they  constitute  the  leonine 
facies  (Fig.  24)  ;  the  eyebrows  are  filled  with  tuberosities  and  their 
hairs  fall.  This  extremely  long  period  is  interrupted  by  acute 
outbreaks,  during  which  the  temperature  rises  to  104°  F.,  and 
there  is  headache,  nausea,  delirium  and  sordes.  During  the  fol- 
lowing days  arthralgia  occurs,  and  a  veritable  erythema  nodosvun, 
of  which  the  nodes  form  fresh  tubercles,  or  large  specific  sur- 
faces of  pseudo-erysipelas.  In  this  way  is  constituted  tuberous 
leprosy,  which  gives  the  patient  a  truly  repulsive  aspect. 

Later  on,  regional  localisation  becomes  pronounced,  The  eye 
is  one  of  the  organs  most  frequently  attacked,  with  leprous  kera- 
titis, infiltration,  phlyctenules,  and  ulceration  of  the  sclerotic  and 
cornea,  and  later  on  pannus. 

There  is  also  a  leprous  iritis.  In  the  larynx,  infiltration  of  the 
vocal  cords  produces  aphonia,  and  in  the  later  stages  laryngeal 
stenosis.  In  the  pharynx  there  is  produced  a  diffuse  leproma, 
which  always  remains  chronic  and  sometimes  ulcerates.  The 
tongue  presents  sclerosing  glossitis,  very  syphiloid  in  appearance. 

There  is  a  leprous  orchitis,  and  infiltration  and  tubercles  of  the 
penis  constituting  a  leprous  pseudo-phimosis.  All  the  viscera 
a'e  more  or  less  affected.  The  spleen  and  all  the  glands  are  en- 
larged and  there  are  bacillary  localisations  on  the  peritoneum. 
Pulmonary  tuberculosis  often  follows,  due  to  the  bacillus  of  Koch. 

Ulcerative  period.  In  the  course  of  tubercular  leprosy,  the  soften- 
ing of  the  tubercles  may  convert  them  into  ulcerative  lesions. 
This  occurs  in  all  lepromas  in  certain  severe  cases.  The  patient 
is  then  covered  with  terrible  phagedenic  sores.  Bony  necrosis 
may  occur  with  loss  of  the  phalanges  (p.  339)  ;  and  saddle  nose 
deformity   and   perforation   of  the   septum   resembling  syphilis. 


CHRONIC    INFECTIOUS    DERMATOSES. 


657 


After  10  or  15  years  cachexia  sets  in  with  interminable  suppura- 
tion and  visceral  infiltration. 

The  leper  having  become  blind,  paralysed,  and  indifferent  to 
everything,  slowly  succumbs.  A  secondary  infection  closes  the 
scene;  septicaemia,  malaria  or  tetanus.  The  form  which  we  have 
described  is  an  average  one.  In  certain  countries  there  are  rare 
cases  of  leprosy  which  are  much  more  rapidly  fatal.  Inversely, 
in  our  country  patients  are  seen  whose  acute  crises  become  grad- 
ually less  frequent  and  less  severe,  and  in  whom  the  disease  with- 
out being  cured,  becomes  progressively  attenuated. 


Fig.  231.     Macular   leprosy.      (Besnier's  patient.      St.    I-ouif   Hosp.    Museum,    No.    626.) 


Anaesthetic  Leprosy.  Anaesthetic  leprosy  is  quite  different, 
but  may  also  be  considered  schematically  as  composed  of 
tliree  phases;  a  hyperccsthctic  phase,  an  anccsthctic  phase,  and  an 
amyotrophic  phase. 

Hyperccsthctic  phase.    This  commences  with  the  macular  eruption 

wdiich  occurs  at  the  onset  of  all  forms  of  leprosy.     The  spots  do 

not    become    papular,   but   pigmented,   and   extend,    wdiile   their 

centre  becomes  white,     (vitiligo  gravior.)     Sometimes  pemphi- 

42 


658  CHRONIC    INFECTIOUS    DERMATOSES. 

goid  bullae  occur  apart  from  the  spots,  sometimes  on  them.  The 
spots  become  the  c'^ntre  of  progressive  sensory  disorders.-  These 
at  first  consist  of  neuralgic  pains  and  tingling  and  burning  sen- 
sations.    This  phase  may  not  be  very  marked. 

Anesthetic  phase.  This  is  never  absent.  The  anaesthesia  results 
from  neuritis,  and  the  nerves  which  are  palpable  (the  ulnar)  pre- 
sent a  series  of  perceptible  nodules.  The  anaesthesia  is  generally 
symmetrical  and  localised  to  the  limbs ;  more  pronounced  in  the 
lower  limbs  and  on  the  surface  than  deeply ;  at  first  in  bands,  after- 
wards segmentary.  Anaesthesia  to  heat  occurs  first  and  is  fol- 
lowed by  anaesthesia  to  pain;  tactile  sensation  remains.  The 
sweat  function  is  suppressed  and  the  sebaceous  secretion  in- 
creased. Trophic  disorders  are  manifested  by  bullous  outbreaks, 
or  leprous  pemphigus,  which  is  especially  common  on  the  elbows, 
knees  and  backs  of  the  hands  and  feet;  often  sloughy,  and  suc- 
ceeded by  perforating  and  mutilating  ulcers.  At  the  same  time 
the  lower  limbs  become  pachydermatous  and  elephantiasic. 

Amyotrophic  phase.  Amyotrophia  is  the  rule.  In  the  more  com- 
mon type  the  atrophy  affects  the  thenar  and  hypothenar  emi- 
nences, then  the  forearms;  the  fingers  are  claw  shaped  or  de- 
^iated  laterally,  as  in  nodular  rheumatism.  In  the  lower  limbs 
a  condition  of  leprous  pseudo-tabes  occurs,  with  tendinous  con- 
tractions, claw  shaped  toes,  etc. 

Bony  and  articular  lesions  are  produced  in  trophoneurotic  lep- 
rosy and  create  mutilations.  Panaris  occurs  with  inflammatory 
phenomena  and  progressive  ulceration;  onychia  and  ulcerative  per- 
ioychia  and  perforating  ulcer.  The  phalanges  of  the  fingers  and 
toes  become  detached  (Fig.  i66)  and  th    extremities  become  stumps. 

The  duration  of  leprosy  is  unlimited.  However,  a  secondary 
infection  may  easily  arise  in  the  emaciated,  paralysed  and 
mummified  patient,  and  prove  fatal. 

Leprosy  requires  rules  of  prophylaxis  and  treatment :  prophy- 
laxis, because  the  disease  is  not  hereditary  but  only  contagious. 
A  new'ly  born  child  when  removed  from  its  leprous  mother  never 
becomes  leprous,  except  by  another  contagion.  The  sequestra- 
tion of  lepers  is  a  problem,  the  study  of  which  is  reserved  for 
countries  in  which  leprosy  is  endemic.  At  the  St.  Louis  Hospi- 
tal, within  the  memory  of  man.  not  a  single  contamination  has 
been  produced,  in  spite  of  the  fact  that  there  have  always  been 
from  12  to  15  lepers  there,  during  more  than  a  century. 


CHRONIC    INFECTIOUS    DERxMATOSES.  659 

There  is  no  specific  treatment  for  leprosy.  Chaulmoogra  oil 
in  doses  of  50  to  200  drops  is  the  most  active  treatment  in  our 
country.  Naphthol  has  given  some  good  results.  The  best  treat- 
men  for  colonial  cases  is  to  return  to  Europe.  They  are  not  cured, 
but  they  live. 

GLANDERS. 

Glanders  is  a  specific  contagious  disease,  most  often  inoculated 
in  man  from  the  horse,  inoculable  in  laboratory  animals,  and 
caused  by  the  bacillus  discovered  by  LoeMer. 

Glanders  is  rare  in  man,  but  sometimes  occurs  in  knackers  and 
veterinary  attendants,  etc.  It  has  been  known  several  times  to 
have  followed  accidental  inoculation  in  the  laboratory. 

It  assumes  two  forms :  an  acute  form  in  which  the  infection 
invades  the  pharyngeal  mucous  membrane  and  the  viscera,  which 
does  not  occur  in  man ;  and  chronic  farcy,  which  is  the  only  form 
seen  in  man.  At  the  point  of  inoculation  is  produced  an  ulcerative 
chancre  with  a  tendency  to  extend  and  become  phagedenic. 
Lymphangitis  with  lymphatic  induration  follows,  forming  the 
farcy  buds.  These  indurations  become  ulcerated  and  also  give 
rise  to  fresh  ulcers.  Adenitis  is  next  produced,  which  also  ulcer- 
ates, causing  farcy  buboes.  After  some  months  visceral  miliary 
foci  are  generally  produced,  causing  acute  miliary  pulmonary 
glanders  or  pneumonia,  which  prove  fatal  in  a  patient  already 
cachectic.  Human  glanders  is  seldom  cured,  and  a  fatal  termina- 
tion  is   the   rule. 

The  treatment  attempted  has  copied  that  of  syphilis.  Mer- 
curial inunction  may  be  tried  on  the  affected  parts,  but  usually 
everything  fails. 

The  diagnosis  is  always  doubtful  at  first,  on  account  of  the 
rarity  of  cases  of  human  glanders,  and  is  always  experimental. 
Inoculation  of  pus  in  the  peritoneum  of  the  male  guinea-pig  deter- 
mines in  5  to  8  hours  an  acute  inflammatory  orchitis.  Pus  taken 
from  the  tunica  vaginalis  of  the  guinea-pig  after  the  orchitis  is 
impure,  because  the  tunica  vaginalis  communicates  freely  with 
the  peritoneum.  But  with  this  pus  it  is  easy  to  make  microbial 
separations,  even  on  glycerinated  gelose-peptone,  by  successive 
dilutions  in  distilled  water  from  several  successive  culture  tubes 
{Vcillon's  method).     The  culture  of  the  bacillus  of  glanders  on 


66o  CHRONIC    INFECTIOUS    DERiMATOSES. 

potato    is   characteristic,   and   its   brown   colour    renders    it   easily 
recognisable. 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 
Los  Angeles 

This  book  is  DUE  on  the  last  date  stamped  below. 


Form  L9-Series  4939 


UC  SOUTHERN  REGIONAL  UBRARY  FAOUTY 


A     000  356  133     9 


